1003114810 NPI number — VICTOR COMMUNITY SUPPORT SERVICES, 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 1003114810 NPI number — VICTOR COMMUNITY SUPPORT SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTOR COMMUNITY SUPPORT SERVICES, 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:
1003114810
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5361
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95927-5361
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-893-0758
Provider Business Mailing Address Fax Number:
530-893-0502

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1545 S HOLT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95206-9618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-969-5258
Provider Business Practice Location Address Fax Number:
530-230-1265
Provider Enumeration Date:
03/02/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WIECHERT
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
FINANCIAL ANALYST
Authorized Official Telephone Number:
530-230-1210

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01042 . This is a "LEGAL ENTITY #" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".