=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114368883
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORY CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2013
-----------------------------------------------------
Last Update Date | 07/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 THOUSAND OAKS DR SUITE 102
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78232-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-348-6377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2828 THOUSAND OAKS DR SUITE 102
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78232-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-348-6377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON WILKINSON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 210-348-6377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 10683
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------