Healthcare Provider Details

I. General information

NPI: 1982237327
Provider Name (Legal Business Name): VICTORIA LOUISA WALLER DC, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VICTORIA SIMPSON DC, ATC

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3646 MIDWAY DR # B
SAN DIEGO CA
92110-5201
US

IV. Provider business mailing address

3646 MIDWAY DR # B
SAN DIEGO CA
92110-5201
US

V. Phone/Fax

Practice location:
  • Phone: 619-223-1617
  • Fax:
Mailing address:
  • Phone: 619-317-1225
  • Fax: 619-223-1618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34763
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberBOC314534
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: