Provider Demographics
NPI:1861004517
Name:VICTORY, CHRISTOPHER
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:
Last Name:VICTORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21911 S EDGAR ST
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-3513
Mailing Address - Country:US
Mailing Address - Phone:310-720-3128
Mailing Address - Fax:
Practice Address - Street 1:1985 ZONAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-5305
Practice Address - Country:US
Practice Address - Phone:323-442-1369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-23
Last Update Date:2020-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46639390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program