Healthcare Provider Details

I. General information

NPI: 1770058265
Provider Name (Legal Business Name): VICTORY MEDICAL TRANSPORTATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 06/25/2024
Certification Date: 06/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3604 S BANNER ST STE 102
BOISE ID
83709-4316
US

IV. Provider business mailing address

29222 RANCHO VIEJO RD STE 127
SAN JUAN CAPISTRANO CA
92675-1049
US

V. Phone/Fax

Practice location:
  • Phone: 208-401-1400
  • Fax: 208-401-1401
Mailing address:
  • Phone: 949-426-3767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code341600000X
TaxonomyAmbulance
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3416A0800X
TaxonomyAir Ambulance
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: TANGINA MALOOF
Title or Position: TREASURER
Credential:
Phone: 469-636-5055