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General NPI Number Information
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NPI Number | 1508320623
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Entity Type | Organization
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Legal Business Name | VICTORY TREATMENT PROGRAM, LLC
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Dates
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Enumeration Date | 01/23/2019
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Last Update Date | 01/23/2019
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Provider Practice Location Address
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Address Line | 9051 EXECUTIVE PARK DR STE 202
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City | KNOXVILLE
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State | TN
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Zip | 37923-4626
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Country | US
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Telephone | 865-337-7812
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Fax | 865-240-3539
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Provider Business Mailing Address
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Address Line | 9051 EXECUTIVE PARK DR STE 202
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City | KNOXVILLE
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State | TN
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Zip | 37923-4626
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Country | US
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Telephone | 865-337-7812
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Fax | 865-240-3539
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Authorized Official
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Title or Position | OWNER
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Name | TRACEY R. MALTMAN
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Credential | NP
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Telephone | 865-337-7812
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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