1134286784 NPI number — VICTORY HEALTHCARE INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134286784 NPI number — VICTORY HEALTHCARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY HEALTHCARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134286784
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4705 DRESDEN VLG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27604-4983
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-846-9027
Provider Business Mailing Address Fax Number:
919-870-9263

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 W MILLBROOK RD
Provider Second Line Business Practice Location Address:
SUITE 9
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609-4380
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-846-9027
Provider Business Practice Location Address Fax Number:
919-870-9263
Provider Enumeration Date:
01/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ILOABACHIE
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
I
Authorized Official Title or Position:
AGENCY DIRECTOR
Authorized Official Telephone Number:
919-846-9027

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC3446 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6601591 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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