Basic Information
| Provider Information | |||||||||
| NPI: | 1851343909 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTORIA OF TEXAS LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DETAR HEALTHCARE SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2089 | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779022089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615757441 | ||||||||
| FaxNumber: | 3617886114 | ||||||||
| Practice Location | |||||||||
| Address1: | 506 E SAN ANTONIO ST | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779016060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615757441 | ||||||||
| FaxNumber: | 3617882693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 04/22/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LALOR | ||||||||
| AuthorizedOfficialFirstName: | PAULA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/DELEGATED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6292153953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | N | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical | 261QC0050X | N | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital | 282N00000X | 000453 | TX | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0941189-02 | 05 | TX | MEDICAID | 0941189-01 | 05 | TX | MEDICAID |