Healthcare Provider Details

I. General information

NPI: 1760533483
Provider Name (Legal Business Name): VICTORY PHYSICAL THERAPY & REHAB CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6554 FLORIDA BLVD SUITE 119
BATON ROUGE LA
70806-4474
US

IV. Provider business mailing address

PO BOX 45985
BATON ROUGE LA
70895-4985
US

V. Phone/Fax

Practice location:
  • Phone: 225-248-0085
  • Fax: 225-248-0086
Mailing address:
  • Phone: 225-248-0085
  • Fax: 225-248-0086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State

VIII. Authorized Official

Name: MR. AYODEJI O FAMUYIDE
Title or Position: DIRECTOR
Credential: M.ED, P.T.
Phone: 225-248-0085