Healthcare Provider Details

I. General information

NPI: 1104540079
Provider Name (Legal Business Name): VICTORY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2022
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 SOUTHWIND DR
JUNCTION CITY KS
66441-9021
US

IV. Provider business mailing address

715 SOUTHWIND DR
JUNCTION CITY KS
66441-9021
US

V. Phone/Fax

Practice location:
  • Phone: 785-209-3779
  • Fax: 785-209-3780
Mailing address:
  • Phone: 785-209-3779
  • Fax: 785-209-3780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRISTIE M CLARK
Title or Position: OWNER
Credential: MD
Phone: 719-698-7933