Provider Demographics
NPI:1619172467
Name:VICTORIA OF TEXAS LP
Entity Type:Organization
Organization Name:VICTORIA OF TEXAS LP
Other - Org Name:DETAR SENIOR CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-892-9813
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:605 E SAN ANTONIO ST
Practice Address - Street 2:SUITE 310E
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-6040
Practice Address - Country:US
Practice Address - Phone:361-575-0228
Practice Address - Fax:361-575-0782
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICTORIA OF TEXAS LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-20
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093825001Medicaid
00GT06OtherBLUE CROSS
CB6305Medicare PIN
00GT06OtherBLUE CROSS