Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XL0004X | Low Vision | 0119005673 | VA |
NPI | 1245799428 |
---|---|
Provider Name | Callie Victor |
First Address | Burke, VA 22015-3735 |
Second Address | Alexandria, VA 22314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 18/03/2019 |
Last Update Date | 18/03/2019 |