Provider Demographics
NPI:1497245971
Name:VICTORY REHABILITATION LLC
Entity Type:Organization
Organization Name:VICTORY REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:JERISON
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPEER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-507-5917
Mailing Address - Street 1:122 ENTERPRISE CT STE E
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-3651
Mailing Address - Country:US
Mailing Address - Phone:706-507-5917
Mailing Address - Fax:706-887-4818
Practice Address - Street 1:122 ENTERPRISE CT STE E
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-3651
Practice Address - Country:US
Practice Address - Phone:705-507-5917
Practice Address - Fax:706-887-4818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy