Provider Demographics
NPI:1992162325
Name:VICTORY CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:VICTORY CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDJAJA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:754-215-6502
Mailing Address - Street 1:3500 N STATE ROAD 7
Mailing Address - Street 2:STE 480
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-5600
Mailing Address - Country:US
Mailing Address - Phone:754-215-6502
Mailing Address - Fax:954-533-5242
Practice Address - Street 1:3500 N STATE ROAD 7
Practice Address - Street 2:STE 480
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5600
Practice Address - Country:US
Practice Address - Phone:754-215-6502
Practice Address - Fax:954-533-5242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-15
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11707111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty