Provider Demographics
NPI:1043022528
Name:VICTORY SPINAL CARE LLC
Entity type:Organization
Organization Name:VICTORY SPINAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERED
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:573-837-9107
Mailing Address - Street 1:1424 KURRE LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2254
Mailing Address - Country:US
Mailing Address - Phone:573-579-5672
Mailing Address - Fax:
Practice Address - Street 1:5849 BUFFALO GAP RD STE D
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-1263
Practice Address - Country:US
Practice Address - Phone:325-632-0586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty