Provider Demographics
NPI:1295190866
Name:VICTORIA, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:VICTORIA
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 1:2981 CROOKED CREEK DR
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3541 PUENTE AVE
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5534
Practice Address - Country:US
Practice Address - Phone:626-962-1043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-23
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260569164X00000X
CA3427224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No164X00000XNursing Service ProvidersLicensed Vocational Nurse