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General NPI Number Information
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NPI Number | 1932916863
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Entity Type | Organization
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Legal Business Name | VICTORY SPINAL CARE LLC
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Dates
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Enumeration Date | 12/13/2024
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Last Update Date | 12/13/2024
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Provider Practice Location Address
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Address Line | 5085 E 151ST ST S STE B
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City | BIXBY
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State | OK
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Zip | 74008-4016
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Country | US
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Telephone | 918-366-7100
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Fax |
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Provider Business Mailing Address
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Address Line | 1424 KURRE LN
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City | CAPE GIRARDEAU
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State | MO
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Zip | 63701-2254
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | JERED WAYLAND
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Credential | DC
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Telephone | 918-366-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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