Provider Demographics
NPI:1861200016
Name:GOLOVANYUK, VICTOR
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:GOLOVANYUK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13492 RESERACH BLVD. STE 120
Mailing Address - Street 2:#186
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750
Mailing Address - Country:US
Mailing Address - Phone:315-350-0770
Mailing Address - Fax:
Practice Address - Street 1:7101 W US HIGHWAY 71 # 1A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-8307
Practice Address - Country:US
Practice Address - Phone:512-529-0027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX123984225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist