Provider Demographics
NPI:1659595254
Name:VICTORY PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:VICTORY PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:718-761-0017
Mailing Address - Street 1:2550 VICTORY BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6635
Mailing Address - Country:US
Mailing Address - Phone:718-761-0017
Mailing Address - Fax:718-761-6980
Practice Address - Street 1:2550 VICTORY BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6635
Practice Address - Country:US
Practice Address - Phone:718-761-0017
Practice Address - Fax:718-761-6980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010846225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ6WSZ1Medicare ID - Type UnspecifiedPHYSICAL THERAPY PROVIDER