Provider Demographics
NPI:1467220871
Name:VICTORY HEALTHCARE LLC
Entity Type:Organization
Organization Name:VICTORY HEALTHCARE LLC
Other - Org Name:VICTORY DIABETES AND PRIMARY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:304-551-2496
Mailing Address - Street 1:1430 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2901
Mailing Address - Country:US
Mailing Address - Phone:253-331-2381
Mailing Address - Fax:253-201-6070
Practice Address - Street 1:1430 16TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2901
Practice Address - Country:US
Practice Address - Phone:253-331-2381
Practice Address - Fax:253-201-6070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty