Provider Demographics
NPI:1245379494
Name:MT VICTORY FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:MT VICTORY FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RECOB
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:937-354-2028
Mailing Address - Street 1:460 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MT VICTORY
Mailing Address - State:OH
Mailing Address - Zip Code:43340
Mailing Address - Country:US
Mailing Address - Phone:937-354-2028
Mailing Address - Fax:934-354-2029
Practice Address - Street 1:460 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MT VICTORY
Practice Address - State:OH
Practice Address - Zip Code:43340
Practice Address - Country:US
Practice Address - Phone:937-354-2028
Practice Address - Fax:934-354-2029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005413R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0937795Medicaid
OH0937795Medicaid