Provider Demographics
NPI:1609393396
Name:VICTORY PERFORMANCE AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:VICTORY PERFORMANCE AND PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SANTO
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-775-0558
Mailing Address - Street 1:10458 LORENZO PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4451
Mailing Address - Country:US
Mailing Address - Phone:310-775-0558
Mailing Address - Fax:
Practice Address - Street 1:11461 W WASHINGTON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-6014
Practice Address - Country:US
Practice Address - Phone:310-775-0558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-24
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT379342251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty