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General NPI Number Information
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NPI Number | 1699888636
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Entity Type | Organization
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Legal Business Name | VICTORY PHYSICAL THERAPY AND WELLNESS SPECIALISTS
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 03/10/2008
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Provider Practice Location Address
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Address Line | 3908 HALL AVE SUITE A
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City | MARINETTE
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State | WI
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Zip | 54143-1018
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Country | US
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Telephone | 715-732-4127
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Fax | 715-732-4137
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Provider Business Mailing Address
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Address Line | PO BOX 3497
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City | STURTEVANT
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State | WI
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Zip | 53177-0300
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Country | US
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Telephone | 877-552-2996
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Fax | 886-245-8064
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Authorized Official
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Title or Position | CO-OWNER
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Name | LARRY BRIAND
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Credential | PT, ATC
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Telephone | 877-552-2996
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 9832024
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License Number State | WI
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