Provider Demographics
NPI:1689009896
Name:KOO, VICTORIA (DOM, LMT)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:KOO
Suffix:
Gender:F
Credentials:DOM, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 ACADEMY RD NE
Mailing Address - Street 2:922
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-7552
Mailing Address - Country:US
Mailing Address - Phone:505-359-1608
Mailing Address - Fax:
Practice Address - Street 1:11600 ACADEMY RD NE
Practice Address - Street 2:922
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-7552
Practice Address - Country:US
Practice Address - Phone:505-359-1608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1215171100000X
NM7593225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No171100000XOther Service ProvidersAcupuncturist