Basic Information
| Provider Information | |||||||||
| NPI: | 1952636060 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTORIA OF TEXAS LP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DETAR HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 3617886114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2009 | ||||||||
| LastUpdateDate: | 10/07/2009 | ||||||||
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| AuthorizedOfficialLastName: | HOLTSFORD | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 6154657466 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VICTORIA OF TEXAS LP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 000453 | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 094118901 | 05 | TX | MEDICAID |