Provider Demographics
NPI:1912965898
Name:VICTORY HEALTH CLINIC LLC
Entity Type:Organization
Organization Name:VICTORY HEALTH CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WEEMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:580-371-8500
Mailing Address - Street 1:705 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-1734
Mailing Address - Country:US
Mailing Address - Phone:580-371-2002
Mailing Address - Fax:580-371-2058
Practice Address - Street 1:714 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2350
Practice Address - Country:US
Practice Address - Phone:580-371-8500
Practice Address - Fax:580-371-2282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC5163OtherRR MEDICARE
DC5163OtherRR MEDICARE