Provider Demographics
NPI:1679393250
Name:VICTORY ATHLETIC EXCHANGE
Entity type:Organization
Organization Name:VICTORY ATHLETIC EXCHANGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:CANDANOZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:424-383-4905
Mailing Address - Street 1:3915 H ST APT D
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-1880
Mailing Address - Country:US
Mailing Address - Phone:360-409-1031
Mailing Address - Fax:
Practice Address - Street 1:3915 H ST APT D
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-1880
Practice Address - Country:US
Practice Address - Phone:360-409-1031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management