Provider Demographics
NPI:1891866596
Name:TOURLUK JR., VICTOR
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:TOURLUK JR.
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2288 N SIERRA WAY
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3544
Mailing Address - Country:US
Mailing Address - Phone:909-475-8724
Mailing Address - Fax:909-475-8126
Practice Address - Street 1:2288 N SIERRA WAY
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3544
Practice Address - Country:US
Practice Address - Phone:909-475-8724
Practice Address - Fax:909-475-8126
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000760Medicaid
CAGXC000760Medicaid