Provider Demographics
NPI:1932916863
Name:VICTORY SPINAL CARE LLC
Entity type:Organization
Organization Name:VICTORY SPINAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERED
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-366-7100
Mailing Address - Street 1:1424 KURRE LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2254
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5085 E 151ST ST S STE B
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-4016
Practice Address - Country:US
Practice Address - Phone:918-366-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty