Provider Demographics
NPI:1942309604
Name:VICTORY PHYSICAL THERAPY PC
Entity Type:Organization
Organization Name:VICTORY PHYSICAL THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:856-223-8898
Mailing Address - Street 1:108 SWEDESBORO RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-1800
Mailing Address - Country:US
Mailing Address - Phone:856-223-8898
Mailing Address - Fax:856-223-8799
Practice Address - Street 1:108 SWEDESBORO RD
Practice Address - Street 2:SUITE 10
Practice Address - City:MULLICA HILL
Practice Address - State:NJ
Practice Address - Zip Code:08062-1800
Practice Address - Country:US
Practice Address - Phone:856-223-8898
Practice Address - Fax:856-223-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJQA005763261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0332711000OtherPERSONAL CHOICE
NJ2139173OtherAETNA
NJ0332711000OtherAMERIHEALTH
NJ025701Medicare ID - Type Unspecified