1497798284 NPI number — VICTORY CLINICAL SERVICES II LLC

Table of content: (NPI 1497798284)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497798284 NPI number — VICTORY CLINICAL SERVICES II LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY CLINICAL SERVICES II 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:
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:
1497798284
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4218 W WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46619-2622
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-233-1524
Provider Business Mailing Address Fax Number:
574-233-1612

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4218 W WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46619-2622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-233-1524
Provider Business Practice Location Address Fax Number:
574-233-1612
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLANKENSHIP
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATIVE DIRECTOR
Authorized Official Telephone Number:
574-233-1524

Provider Taxonomy Codes

  • Taxonomy code: 103TH0100X , with the licence number:  20010221A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QA0401X , with the licence number: 02001493A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 71001833A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1255432233 . This is a "WOODWARD NPC - NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 168750 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100220790 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200495610 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1518055565 . This is a "SHEEHAN HSPP - NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 1982647434 . This is a "WANG - NPI" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com