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General NPI Number Information
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NPI Number | 1104540079
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Entity Type | Organization
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Legal Business Name | VICTORY CLINIC LLC
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Dates
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Enumeration Date | 10/03/2022
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Last Update Date | 01/09/2026
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Provider Practice Location Address
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Address Line | 715 SOUTHWIND DR
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City | JUNCTION CITY
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State | KS
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Zip | 66441-9021
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Country | US
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Telephone | 785-209-3779
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Fax | 785-209-3780
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Provider Business Mailing Address
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Address Line | 715 SOUTHWIND DR
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City | JUNCTION CITY
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State | KS
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Zip | 66441-9021
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Country | US
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Telephone | 785-209-3779
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Fax | 785-209-3780
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Authorized Official
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Title or Position | OWNER
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Name | KRISTIE M CLARK
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Credential | MD
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Telephone | 719-698-7933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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