Provider Demographics
NPI:1164291779
Name:ANTIGUA, VICTOR MANUEL
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
Last Name:ANTIGUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11265 NW 78TH ST
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-1464
Mailing Address - Country:US
Mailing Address - Phone:786-609-3609
Mailing Address - Fax:
Practice Address - Street 1:11265 NW 78TH ST
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-1464
Practice Address - Country:US
Practice Address - Phone:786-609-3609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician