Provider Demographics
NPI:1366806358
Name:VICTORY LIFE HEALTH SERVICES
Entity type:Organization
Organization Name:VICTORY LIFE HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-456-1225
Mailing Address - Street 1:6221 ROUTE 474
Mailing Address - Street 2:
Mailing Address - City:ASHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14710-9788
Mailing Address - Country:US
Mailing Address - Phone:716-782-4158
Mailing Address - Fax:
Practice Address - Street 1:95 E HIGH ST STE 104
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:PA
Practice Address - Zip Code:15370-1853
Practice Address - Country:US
Practice Address - Phone:716-456-1225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty