Provider Demographics
NPI:1780285510
Name:VICTORY SPINE AND SPORT PLLC
Entity type:Organization
Organization Name:VICTORY SPINE AND SPORT PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-818-4626
Mailing Address - Street 1:16508 SE 24TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-4321
Mailing Address - Country:US
Mailing Address - Phone:360-818-4626
Mailing Address - Fax:360-208-0293
Practice Address - Street 1:16508 SE 24TH ST STE 203
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-4321
Practice Address - Country:US
Practice Address - Phone:360-818-4626
Practice Address - Fax:360-208-0293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-06
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center