Healthcare Provider Details

I. General information

NPI: 1891935763
Provider Name (Legal Business Name): VICTORY ORTHOTICS & PROSTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SHERIDAN SQ SUITE 100
KINGSPORT TN
37660
US

IV. Provider business mailing address

2 SHERIDAN SQ SUITE 100
KINGSPORT TN
37660-7399
US

V. Phone/Fax

Practice location:
  • Phone: 423-378-3320
  • Fax: 423-378-3363
Mailing address:
  • Phone: 423-378-3320
  • Fax: 423-378-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateTN

VIII. Authorized Official

Name: MR. BRAD GARDNER
Title or Position: COO
Credential:
Phone: 615-864-8790