Provider Demographics
NPI:1609204759
Name:VICTORY MEDICAL CLINIC
Entity Type:Organization
Organization Name:VICTORY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-957-2336
Mailing Address - Street 1:8636 MARKS ST
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70118-4628
Mailing Address - Country:US
Mailing Address - Phone:504-957-2336
Mailing Address - Fax:504-942-8701
Practice Address - Street 1:9970 LAKE FOREST BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-2609
Practice Address - Country:US
Practice Address - Phone:504-957-2336
Practice Address - Fax:504-942-8700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care