Provider Demographics
NPI:1700458585
Name:MOSES, VICTORIA ALINE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ALINE
Last Name:MOSES
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:PO BOX 294
Mailing Address - Street 2:
Mailing Address - City:TALIHINA
Mailing Address - State:OK
Mailing Address - Zip Code:74571-0294
Mailing Address - Country:US
Mailing Address - Phone:918-413-9005
Mailing Address - Fax:918-649-0066
Practice Address - Street 1:210 S WILSON ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4917
Practice Address - Country:US
Practice Address - Phone:918-649-0011
Practice Address - Fax:918-649-0066
Is Sole Proprietor?:No
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator