Provider Demographics
NPI:1730403106
Name:PURE VICTORY, LLC
Entity type:Organization
Organization Name:PURE VICTORY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:BOAZ
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-337-7077
Mailing Address - Street 1:800 STATE HWY 248
Mailing Address - Street 2:SUITE 2-B
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616
Mailing Address - Country:US
Mailing Address - Phone:417-337-7077
Mailing Address - Fax:
Practice Address - Street 1:800 STATE HWY 248
Practice Address - Street 2:SUITE 2-B
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616
Practice Address - Country:US
Practice Address - Phone:417-337-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-15
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009032450111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1265755227OtherNPI TYPE I