Healthcare Provider Details

I. General information

NPI: 1821172008
Provider Name (Legal Business Name): VICTORIAN CARE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11149 CRENSHAW BLVD
INGLEWOOD CA
90303-2338
US

IV. Provider business mailing address

PO BOX 88939
LOS ANGELES CA
90009-6939
US

V. Phone/Fax

Practice location:
  • Phone: 310-677-4600
  • Fax: 310-677-4600
Mailing address:
  • Phone: 310-677-4600
  • Fax: 310-914-9705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberW9384
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: NWACHUKWU A. ANAKWENZE
Title or Position: OWNER/DOCTOR
Credential: MD
Phone: 310-677-4600