Provider Demographics
NPI:1730973629
Name:VICTORY SPINAL CARE WACO LLC
Entity type:Organization
Organization Name:VICTORY SPINAL CARE WACO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERED
Authorized Official - Middle Name:
Authorized Official - Last Name:WAYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-334-0010
Mailing Address - Street 1:1424 KURRE LN
Mailing Address - Street 2:
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63701-2254
Mailing Address - Country:US
Mailing Address - Phone:254-296-1325
Mailing Address - Fax:
Practice Address - Street 1:5002 LAKELAND CIR STE B
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2900
Practice Address - Country:US
Practice Address - Phone:254-296-1325
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-07
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty