1063910859 NPI number — VICTORY HEALTH CARE SERVICES LLC

Table of content: (NPI 1063910859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063910859 NPI number — VICTORY HEALTH CARE SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY HEALTH CARE SERVICES LLC
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:
6
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:
1063910859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 E NORTHERN PKWY STE 205207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21239-2113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
443-204-5144
Provider Business Mailing Address Fax Number:
410-617-8478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
499C BEAUMONT AVENUE
Provider Second Line Business Practice Location Address:
SUITE 18
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
443-204-5144
Provider Business Practice Location Address Fax Number:
667-212-2430
Provider Enumeration Date:
01/26/2018

Additional Information

Authorized Official

Authorized Official Last Name:
AKADRI
Authorized Official First Name:
BODE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM DIRECTOR
Authorized Official Telephone Number:
443-204-5144

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 666466100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1972978716 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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