Healthcare Provider Details

I. General information

NPI: 1326026014
Provider Name (Legal Business Name): VICTORY HOME HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E MAIN ST
TISHOMINGO OK
73460-2350
US

IV. Provider business mailing address

714 E MAIN ST
TISHOMINGO OK
73460-2350
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2002
  • Fax: 580-371-2058
Mailing address:
  • Phone: 580-371-2002
  • Fax: 580-371-2262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number7542
License Number StateOK

VIII. Authorized Official

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