Healthcare Provider Details

I. General information

NPI: 1821076506
Provider Name (Legal Business Name): VICTORY HOSPICE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 THOMA DR STE 1
ELGIN OK
73538-2203
US

IV. Provider business mailing address

PO BOX 769 104 THOMA SUITE 1
ELGIN OK
73538-0769
US

V. Phone/Fax

Practice location:
  • Phone: 580-492-6166
  • Fax: 580-492-6160
Mailing address:
  • Phone: 580-492-6166
  • Fax: 580-492-6160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number4182
License Number StateOK

VIII. Authorized Official

Name: KIM CRIPPS
Title or Position: ADMINISTRATOR
Credential: RN
Phone: 580-371-2002