Provider Demographics
NPI:1245947233
Name:AGBEMAVA, VICTOR
Entity type:Individual
Prefix:MR
First Name:VICTOR
Middle Name:
Last Name:AGBEMAVA
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 1:18806 PROVIDENCE VALLEY TRL
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-2013
Mailing Address - Country:US
Mailing Address - Phone:571-420-4797
Mailing Address - Fax:
Practice Address - Street 1:18806 PROVIDENCE VALLEY TRL
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-2013
Practice Address - Country:US
Practice Address - Phone:571-420-4797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP1600X, 343800000X
TX41531606343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)