Provider Demographics
NPI:1417130055
Name:VICTORIA MARIE GRAZIANO
Entity Type:Organization
Organization Name:VICTORIA MARIE GRAZIANO
Other - Org Name:VICKIS MASTECTOMY BOUTIQUE
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRAZIANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-463-5844
Mailing Address - Street 1:277 N LYNNHAVEN RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-6963
Mailing Address - Country:US
Mailing Address - Phone:757-463-5844
Mailing Address - Fax:757-463-9349
Practice Address - Street 1:277 N LYNNHAVEN RD
Practice Address - Street 2:SUITE 108
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-6963
Practice Address - Country:US
Practice Address - Phone:757-463-5844
Practice Address - Fax:757-463-9349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4718430001Medicare NSC