=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245375179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORY MEDICAL SUPPLY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2007
-----------------------------------------------------
Last Update Date | 03/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8156 S COTTAGE GROVE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60619-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-783-8666
-----------------------------------------------------
Fax | 773-783-8664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8156 S COTTAGE GROVE AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60619-5104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-783-8666
-----------------------------------------------------
Fax | 773-783-8664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRISIDENT
-----------------------------------------------------
Name | MISS VICKY U ANADUMAKA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-783-8666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 203000788
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------