Provider Demographics
NPI:1386872331
Name:VICTORY VISION PC
Entity type:Organization
Organization Name:VICTORY VISION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSELLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:215-833-3465
Mailing Address - Street 1:3507 MANCHESTER EXPY
Mailing Address - Street 2:UNIT 92
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-6400
Mailing Address - Country:US
Mailing Address - Phone:706-327-0111
Mailing Address - Fax:706-327-4980
Practice Address - Street 1:3507 MANCHESTER EXPY
Practice Address - Street 2:UNIT 92
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-6400
Practice Address - Country:US
Practice Address - Phone:706-327-0111
Practice Address - Fax:706-327-4980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-29
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA 002439302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILV06677Medicare UPIN