NPIMap

Organization Active NPI

Victory Orthotics & Prosthetics LLC

  • Prosthetic/Orthotic Supplier
  • Kingsport, TN
National Provider Identifier
1891935763
Registry record updated Oct 3, 2018
On this page

Key facts

NPPES NPI Registry
Primary specialty
Prosthetic/Orthotic SupplierTaxonomy code 335E00000X
Legal business name
VICTORY ORTHOTICS & PROSTHETICS LLC
Practice address
2 Sheridan SQ
Suite 100
Kingsport, TN 37660
Phone
(423) 378-3320
Fax
(423) 378-3363
NPI assigned
Mar 4, 2009
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 3, 2018

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Brad Gardner
Title
Coo
Phone
(615) 864-8790

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Prosthetic/Orthotic Supplier 335E00000X TN Primary

Addresses

Primary practice location

2 Sheridan SQ
Suite 100
Kingsport, TN 37660

Mailing address

2 Sheridan SQ
Suite 100
Kingsport, TN 37660-7399
Phone (423) 378-3320

Other identifiers 3

IdentifierTypeStateIssuer
4017529OtherTNBCBST
9190601MedicaidVA
1454184MedicaidTN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TN

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20120322000176 TN DME Supplier - Prosthetic PersonnelDME Supplier - Orthotic Personnel 9537371406 Practice locations: Kingsport, TN

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

Medicare medical equipment & supply locations

SupplierSuppliesMedicare assignment
Victory Orthotics & Prosthetics LLC2 Sheridan SQ, Kingsport, TN 37660-7399(423) 378-3320 Orthoses: Custom Fabricated|Orthoses: Prefabricated (Non-Custom Fabricated)|Orthoses: Off-The-Shelf|Limb Prostheses|Diabetic Shoes and Inserts|Diabetic Shoes/Inserts - Custom|Lymphedema Compression Treatment Items Does not accept assignmentParticipating since Jan 1, 2019

National Provider Directory

National Provider Directory
Tax ID family
Victory Orthotics Prosthetics LLC3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Locations

2 Sheridan Sq
Ste 100
Kingsport, TN 37660
Phone (423) 378-3320

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1236124800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1538524800000",
    "number": "1891935763",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2 SHERIDAN SQ",
            "address_2": "SUITE 100",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "376607399",
            "telephone_number": "423-378-3320",
            "fax_number": "423-378-3363"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2 SHERIDAN SQ",
            "address_2": "SUITE 100",
            "city": "KINGSPORT",
            "state": "TN",
            "postal_code": "37660",
            "telephone_number": "423-378-3320",
            "fax_number": "423-378-3363"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VICTORY ORTHOTICS & PROSTHETICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2009-03-04",
        "last_updated": "2018-10-03",
        "status": "A",
        "authorized_official_last_name": "GARDNER",
        "authorized_official_first_name": "BRAD",
        "authorized_official_title_or_position": "COO",
        "authorized_official_telephone_number": "615-864-8790",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "335E00000X",
            "taxonomy_group": "",
            "desc": "Prosthetic/Orthotic Supplier",
            "state": "TN",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBST",
            "identifier": "4017529",
            "state": "TN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9190601",
            "state": "VA"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1454184",
            "state": "TN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Kingsport, TN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 3, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.