Provider Demographics
NPI:1316238637
Name:VICTORY TRANSPORT LLC
Entity type:Organization
Organization Name:VICTORY TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TANISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-971-9333
Mailing Address - Street 1:14 VICTORY CT
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-3119
Mailing Address - Country:US
Mailing Address - Phone:989-971-9333
Mailing Address - Fax:
Practice Address - Street 1:14 VICTORY CT
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-3119
Practice Address - Country:US
Practice Address - Phone:989-971-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICTORY AFC I, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)