Provider Demographics
NPI:1811100506
Name:VICTORIA ORTHOPEDIC & SPORTS MEDICINE CLINIC
Entity type:Organization
Organization Name:VICTORIA ORTHOPEDIC & SPORTS MEDICINE CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-576-0633
Mailing Address - Street 1:605 E SAN ANTONIO ST STE 520E
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6086
Mailing Address - Country:US
Mailing Address - Phone:361-576-0633
Mailing Address - Fax:
Practice Address - Street 1:605 E SAN ANTONIO ST STE 520E
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6086
Practice Address - Country:US
Practice Address - Phone:361-576-0633
Practice Address - Fax:361-576-0369
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5492230001Medicare NSC