Provider Demographics
NPI:1790038693
Name:VICTORY CHIROPRACTIC AND PHYSICAL THERAPY
Entity Type:Organization
Organization Name:VICTORY CHIROPRACTIC AND PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NIMPHIUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-251-6767
Mailing Address - Street 1:200 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6238
Mailing Address - Country:US
Mailing Address - Phone:817-251-6767
Mailing Address - Fax:817-251-6868
Practice Address - Street 1:200 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 10
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6238
Practice Address - Country:US
Practice Address - Phone:817-251-6767
Practice Address - Fax:817-251-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9184111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX607138OtherBCBS