Provider Demographics
NPI:1679964274
Name:BOTHE, VICTOR (BC-HIS ACA)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:BOTHE
Suffix:
Gender:M
Credentials:BC-HIS ACA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12503 SE MILL PLAIN BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4007
Mailing Address - Country:US
Mailing Address - Phone:360-567-1717
Mailing Address - Fax:360-567-0977
Practice Address - Street 1:12503 SE MILL PLAIN BLVD STE 220
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-4007
Practice Address - Country:US
Practice Address - Phone:360-567-1717
Practice Address - Fax:360-567-0977
Is Sole Proprietor?:No
Enumeration Date:2015-02-18
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA00000626237700000X
OR358223237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist