Healthcare Provider Details

I. General information

NPI: 1003720574
Provider Name (Legal Business Name): VICTORY SPINAL CARE CLEMSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10873 CLEMSON BLVD UNIT 113
SENECA SC
29678-1397
US

IV. Provider business mailing address

1424 KURRE LN
CAPE GIRARDEAU MO
63701-2254
US

V. Phone/Fax

Practice location:
  • Phone: 814-516-2897
  • Fax:
Mailing address:
  • Phone: 573-334-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERED WAYLAND
Title or Position: OWNER
Credential: DC
Phone: 573-837-9107