Provider Demographics
NPI:1760533483
Name:VICTORY PHYSICAL THERAPY & REHAB CLINIC
Entity Type:Organization
Organization Name:VICTORY PHYSICAL THERAPY & REHAB CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AYODEJI
Authorized Official - Middle Name:O
Authorized Official - Last Name:FAMUYIDE
Authorized Official - Suffix:
Authorized Official - Credentials:MED, PT
Authorized Official - Phone:225-248-0085
Mailing Address - Street 1:PO BOX 45985
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70895-4985
Mailing Address - Country:US
Mailing Address - Phone:225-248-0085
Mailing Address - Fax:225-248-0086
Practice Address - Street 1:6554 FLORIDA BLVD
Practice Address - Street 2:SUITE 119
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-4474
Practice Address - Country:US
Practice Address - Phone:225-248-0085
Practice Address - Fax:225-248-0086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5C929Medicare PIN