Healthcare Provider Details

I. General information

NPI: 1174711642
Provider Name (Legal Business Name): VICTORIA MARTIN P.T.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6056 BOYNTON BEACH BLVD STE. 215
BOYNTON BEACH FL
33437-3584
US

IV. Provider business mailing address

6056 BOYNTON BEACH BLVD STE. 215
BOYNTON BEACH FL
33437-3584
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-6500
  • Fax: 561-340-1307
Mailing address:
  • Phone: 561-967-6500
  • Fax: 561-340-1307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPTA 21008
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: