Provider Demographics
NPI:1982237327
Name:WALLER, VICTORIA LOUISA (DC, ATC)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LOUISA
Last Name:WALLER
Suffix:
Gender:F
Credentials:DC, ATC
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC, ATC
Mailing Address - Street 1:3646 MIDWAY DR # B
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5201
Mailing Address - Country:US
Mailing Address - Phone:619-317-1225
Mailing Address - Fax:619-223-1618
Practice Address - Street 1:3646 MIDWAY DR # B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5201
Practice Address - Country:US
Practice Address - Phone:619-223-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-13
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABOC3145342255A2300X
CA34763111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer