Provider Demographics
NPI:1255662516
Name:VICTORY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:VICTORY WELLNESS CENTER, LLC
Other - Org Name:VICTORY WELLNESS CENTER, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:C.E.O./ CERTIFIED NURSE PRACTITIONE
Authorized Official - Prefix:
Authorized Official - First Name:SUPORIOR
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:251-610-2644
Mailing Address - Street 1:PO BOX 8556
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39535-8556
Mailing Address - Country:US
Mailing Address - Phone:251-610-2644
Mailing Address - Fax:251-639-9707
Practice Address - Street 1:123 CAILLAVET ST
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530-4101
Practice Address - Country:US
Practice Address - Phone:228-386-7487
Practice Address - Fax:228-386-7499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866985261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center