1215579628 NPI number — VICTOR COMMUNITY SUPPORT SERVICES, INC.

Table of content: (NPI 1215579628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215579628 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:
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:
1215579628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1360 E LASSEN AVE
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:
95973-7823
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:
302 CHERRY LN
Provider Second Line Business Practice Location Address:
SUITES 101, 201 & 208
Provider Business Practice Location Address City Name:
MANTECA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95337-4311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-647-6200
Provider Business Practice Location Address Fax Number:
209-647-6210
Provider Enumeration Date:
10/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
WIECHERT
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
DIRECTOR OF FINANCIAL ANALYSIS
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 NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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