1720458300 NPI number — VICTORY THROUGH FAITH RECOVERY SERVIES

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 1720458300 NPI number — VICTORY THROUGH FAITH RECOVERY SERVIES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY THROUGH FAITH RECOVERY SERVIES
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:
THE MICAH HOUSE
Provider Other Organization Name Type Code:
3
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:
1720458300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1523 NICOLLET AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55403-2723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-314-2460
Provider Business Mailing Address Fax Number:
612-871-4290

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1523 NICOLLET AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55403-2723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-314-2460
Provider Business Practice Location Address Fax Number:
612-871-4290
Provider Enumeration Date:
09/25/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKETT
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
612-314-2460

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  1069387 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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