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General NPI Number Information
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NPI Number | 1912965898
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Entity Type | Organization
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Legal Business Name | VICTORY HEALTH CLINIC LLC
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Dates
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Enumeration Date | 05/02/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 714 E MAIN ST
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City | TISHOMINGO
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State | OK
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Zip | 73460-2350
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Country | US
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Telephone | 580-371-8500
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Fax | 580-371-2282
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Provider Business Mailing Address
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Address Line | 705 W MAIN ST
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City | TISHOMINGO
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State | OK
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Zip | 73460-1734
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Country | US
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Telephone | 580-371-2002
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Fax | 580-371-2058
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JOAN WEEMS
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Credential | RN
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Telephone | 580-371-8500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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