Provider Demographics
NPI:1417589532
Name:VIDALES, VICTORIA MICHELLE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:MICHELLE
Last Name:VIDALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S LELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-2434
Mailing Address - Country:US
Mailing Address - Phone:626-552-2293
Mailing Address - Fax:
Practice Address - Street 1:1425 S LELAND AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2434
Practice Address - Country:US
Practice Address - Phone:626-552-2293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer