Provider Demographics
NPI:1427320746
Name:STOVALL, VICTORIA (OWNER)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:STOVALL
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6043 HUDSON RD
Mailing Address - Street 2:SUITE 125
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1018
Mailing Address - Country:US
Mailing Address - Phone:612-735-0610
Mailing Address - Fax:
Practice Address - Street 1:6043 HUDSON RD
Practice Address - Street 2:SUITE 125
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1018
Practice Address - Country:US
Practice Address - Phone:612-735-0610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN45-4425527OtherMASSAGE THERAPIST