Provider Demographics
NPI:1053969196
Name:VICTOR PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:VICTOR PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:GNANAPRAGASAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:317-893-4091
Mailing Address - Street 1:8523 MADISON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-6117
Mailing Address - Country:US
Mailing Address - Phone:317-893-4091
Mailing Address - Fax:
Practice Address - Street 1:8523 MADISON AVE STE D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-6117
Practice Address - Country:US
Practice Address - Phone:317-893-4091
Practice Address - Fax:317-893-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-02
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1750628277OtherNPI
IN13604193OtherCAQH
13604193OtherCAQH