Provider Demographics
NPI:1013038041
Name:VICTORIA ORTHOTIC AND PROSTHETIC SERVICES, INC
Entity Type:Organization
Organization Name:VICTORIA ORTHOTIC AND PROSTHETIC SERVICES, INC
Other - Org Name:VICTORIA BRACE CO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO,; C.O.; L.P.O.
Authorized Official - Prefix:
Authorized Official - First Name:WILFORD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:361-882-4991
Mailing Address - Street 1:1121 MORGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404-3242
Mailing Address - Country:US
Mailing Address - Phone:361-882-4991
Mailing Address - Fax:361-882-4523
Practice Address - Street 1:1121 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-3242
Practice Address - Country:US
Practice Address - Phone:361-882-4991
Practice Address - Fax:361-882-4523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101063335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086148601Medicaid
TX086148602Medicaid
TX086148603Medicaid
TX530911OtherBLUE CROSS BLUE SHIELD TX
TX0497160001Medicare NSC