Healthcare Provider Details

I. General information

NPI: 1487431805
Provider Name (Legal Business Name): VICTORY HEALTH HOME PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2023
Last Update Date: 01/15/2026
Certification Date: 01/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3887 E CITRINE RD
SAN TAN VALLEY AZ
85143-5688
US

IV. Provider business mailing address

3887 E CITRINE RD
SAN TAN VALLEY AZ
85143-5688
US

V. Phone/Fax

Practice location:
  • Phone: 602-502-4872
  • Fax: 480-210-3563
Mailing address:
  • Phone: 480-202-4597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. IBUKUN ODUTOLA
Title or Position: DNP CEO
Credential: PMHNP
Phone: 480-202-4597