Provider Demographics
NPI:1447494950
Name:VICTORY CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:VICTORY CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:VICTORY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:228-497-9907
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-0760
Mailing Address - Country:US
Mailing Address - Phone:228-497-9907
Mailing Address - Fax:228-497-9917
Practice Address - Street 1:315 HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-6340
Practice Address - Country:US
Practice Address - Phone:228-497-9907
Practice Address - Fax:228-497-9917
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS980111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123096Medicaid
MS08755862Medicaid
MS08755862Medicaid