MEDICARE: VICTORY PHYSICAL THERAPY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1447801071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY PHYSICAL THERAPY, PC

Provider Business Mailing Address
First Line	:	2018 ELWOOD BLVD
Second Line	:
City	:	SPRING ARBOR
State	:	MI
Zip	:	49283
Country	:	US
Telephone Number	:	517-945-4030
Fax Number	:	517-750-3269

Provider Business Practice Location Address
First Line	:	2018 ELWOOD BLVD
Second Line	:
City	:	SPRING ARBOR
State	:	MI
Zip	:	49283-9682
Country	:	US
Telephone Number	:	517-945-4030
Fax Number	:	517-750-3269

Authorized Official
Title or Position	:	INCORPORATOR
Name	:	DR. KARTHYAYANI KUNCHAPPA
Credential	:	DPT
Telephone Number	:	517-945-4030

Provider Enumeration Date	:	09/25/2019
Last Update Date	:	09/25/2019

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