Healthcare Provider Details

I. General information

NPI: 1790476489
Provider Name (Legal Business Name): LAURA DENISE VICTORIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA DENISE ESTRADA

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3148 MIDWAY DR # 113
SAN DIEGO CA
92110-4539
US

IV. Provider business mailing address

3148 MIDWAY DR STE 113
SAN DIEGO CA
92110-4539
US

V. Phone/Fax

Practice location:
  • Phone: 619-363-0853
  • Fax: 619-362-9905
Mailing address:
  • Phone: 619-363-0853
  • Fax: 619-362-9905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: