Provider Demographics
NPI:1114412731
Name:VICTORY SURGICAL SERVICES PLLC
Entity Type:Organization
Organization Name:VICTORY SURGICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KERI
Authorized Official - Middle Name:L
Authorized Official - Last Name:HINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-321-4790
Mailing Address - Street 1:8854 W EMERALD ST STE 140
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-4845
Mailing Address - Country:US
Mailing Address - Phone:208-321-4790
Mailing Address - Fax:208-321-4836
Practice Address - Street 1:8854 W EMERALD ST STE 140
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-321-4790
Practice Address - Fax:208-321-4836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty