Basic Information
| Provider Information | |||||||||
| NPI: | 1275802456 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICTOR | ||||||||
| FirstName: | ITORO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 MARIN DRINOV | ||||||||
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| City: | SOFIA | ||||||||
| State: | EUROPE | ||||||||
| PostalCode: | 1000 | ||||||||
| CountryCode: | BG | ||||||||
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| Practice Location | |||||||||
| Address1: | 68 WILLOW RD | ||||||||
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| City: | MENLO PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940253653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668396979 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2011 | ||||||||
| LastUpdateDate: | 07/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 031872 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 36282 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.