Healthcare Provider Details

I. General information

NPI: 1285059352
Provider Name (Legal Business Name): VICTORIA DODGE SFIDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E FLOWER ST APT 76
CHULA VISTA CA
91910-7610
US

IV. Provider business mailing address

50 E FLOWER ST APT 76
CHULA VISTA CA
91910-7610
US

V. Phone/Fax

Practice location:
  • Phone: 602-376-6590
  • Fax:
Mailing address:
  • Phone: 602-376-6590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: