Healthcare Provider Details

I. General information

NPI: 1457069338
Provider Name (Legal Business Name): VICTORIOUS LIFESTYLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/09/2022
Certification Date: 11/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 N 31ST AVE STE C307
PHOENIX AZ
85051-9569
US

IV. Provider business mailing address

1831 E APACHE BLVD APT 2098
TEMPE AZ
85281-6682
US

V. Phone/Fax

Practice location:
  • Phone: 240-397-0554
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHAREKA SHERROD
Title or Position: OWNER
Credential:
Phone: 240-397-0554