Provider Demographics
NPI:1982217782
Name:SHORE, VICTORIA L
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:L
Last Name:SHORE
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 1:602 RIDGEVILLE CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:INMAN
Mailing Address - State:SC
Mailing Address - Zip Code:29349-9620
Mailing Address - Country:US
Mailing Address - Phone:646-384-9261
Mailing Address - Fax:
Practice Address - Street 1:602 RIDGEVILLE CROSSING DR
Practice Address - Street 2:
Practice Address - City:INMAN
Practice Address - State:SC
Practice Address - Zip Code:29349-9620
Practice Address - Country:US
Practice Address - Phone:646-384-9261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021926225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist