Provider Demographics
NPI:1356573166
Name:PARK, VICTORIA C (RD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:C
Last Name:PARK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W MORTON ST STE 114
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-1671
Mailing Address - Country:US
Mailing Address - Phone:903-462-4085
Mailing Address - Fax:817-578-3098
Practice Address - Street 1:2300 W MORTON ST STE 114
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-1671
Practice Address - Country:US
Practice Address - Phone:903-462-4085
Practice Address - Fax:817-578-3098
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX814271133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered