Provider Demographics
NPI:1184777922
Name:CLINICA LA VICTORIA A MEDICAL CORPORATION
Entity type:Organization
Organization Name:CLINICA LA VICTORIA A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORONA
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:661-885-7007
Mailing Address - Street 1:2303 S UNION AVE
Mailing Address - Street 2:SUITE C2
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93307-4677
Mailing Address - Country:US
Mailing Address - Phone:661-885-7007
Mailing Address - Fax:661-735-3699
Practice Address - Street 1:2303 S UNION AVE
Practice Address - Street 2:SUITE C2
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-4677
Practice Address - Country:US
Practice Address - Phone:661-885-7007
Practice Address - Fax:661-735-3699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207V00000X, 208D00000X
CAA61306208D00000X
261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA126239Medicare PIN
CAW19300Medicare PIN
CAGR0092000Medicaid
CACA126239Medicare PIN