Healthcare Provider Details

I. General information

NPI: 1770545873
Provider Name (Legal Business Name): VICTORIA KIDNEY & DIALYSIS ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E SAN ANTONIO SUITE 430E
VICTORIA TX
77901
US

IV. Provider business mailing address

605 E SAN ANTONIO SUITE 430E
VICTORIA TX
77901
US

V. Phone/Fax

Practice location:
  • Phone: 361-576-0011
  • Fax: 361-576-4084
Mailing address:
  • Phone: 361-576-0011
  • Fax: 361-576-4084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MAHAN
Title or Position: MEDICAL MANAGER
Credential:
Phone: 361-576-0011