Healthcare Provider Details

I. General information

NPI: 1356573166
Provider Name (Legal Business Name): VICTORIA C PARK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2009
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 W MORTON ST STE 114
DENISON TX
75020-1671
US

IV. Provider business mailing address

2300 W MORTON ST STE 114
DENISON TX
75020-1671
US

V. Phone/Fax

Practice location:
  • Phone: 903-462-4085
  • Fax: 817-578-3098
Mailing address:
  • Phone: 903-462-4085
  • Fax: 817-578-3098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number814271
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: