Provider Demographics
NPI:1326499419
Name:VICTORY MEDICAL TRANSPORTATION
Entity type:Organization
Organization Name:VICTORY MEDICAL TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:TANGINA
Authorized Official - Middle Name:R
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-636-5055
Mailing Address - Street 1:3604 S BANNER ST STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-4316
Mailing Address - Country:US
Mailing Address - Phone:208-321-1703
Mailing Address - Fax:
Practice Address - Street 1:3604 S BANNER ST STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-4316
Practice Address - Country:US
Practice Address - Phone:208-321-1703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-29
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)