Provider Demographics
NPI:1275840407
Name:VICTORY MEDICAL EQUIPMENT OF TX
Entity Type:Organization
Organization Name:VICTORY MEDICAL EQUIPMENT OF TX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BOLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-868-0308
Mailing Address - Street 1:809 GALLAGHER DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:SHERMAN
Mailing Address - State:TX
Mailing Address - Zip Code:75090-3111
Mailing Address - Country:US
Mailing Address - Phone:903-868-0308
Mailing Address - Fax:903-868-0207
Practice Address - Street 1:2501 N CENTER ST
Practice Address - Street 2:SUITE 105
Practice Address - City:BONHAM
Practice Address - State:TX
Practice Address - Zip Code:75418-2114
Practice Address - Country:US
Practice Address - Phone:903-583-3562
Practice Address - Fax:903-583-8636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICTORY MEDICAL EQUIPMENT OF TX
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0099790332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX192165201Medicaid
TX6059030001Medicare Oscar/Certification