Healthcare Provider Details

I. General information

NPI: 1700517265
Provider Name (Legal Business Name): VICTORY RECOVERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2022
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 E UNIVERSITY DR STE B
MESA AZ
85203-8000
US

IV. Provider business mailing address

1045 E UNIVERSITY DR STE B
MESA AZ
85203-8000
US

V. Phone/Fax

Practice location:
  • Phone: 480-416-4813
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0401X
TaxonomyComprehensive Outpatient Rehabilitation Facility (CORF)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MAX HALL
Title or Position: CO-OWNER
Credential:
Phone: 480-416-4813