Provider Demographics
NPI:1023123486
Name:BOLDUC, VICTORIA (PT)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:11135 S JOG ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437-1817
Mailing Address - Country:US
Mailing Address - Phone:561-752-3820
Mailing Address - Fax:567-752-5788
Practice Address - Street 1:11135 S JOG ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33737-1817
Practice Address - Country:US
Practice Address - Phone:561-752-3820
Practice Address - Fax:567-752-5788
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9635 PT225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4872Medicare ID - Type Unspecified