Healthcare Provider Details

I. General information

NPI: 1669703427
Provider Name (Legal Business Name): VICTOR COMMUNITY SUPPORT SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2010
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 SAN JACINTO RIVER RD SUITE 106, 107, 201-207
LAKE ELSINORE CA
92530
US

IV. Provider business mailing address

1360 E LASSEN AVE
CHICO CA
95973-7823
US

V. Phone/Fax

Practice location:
  • Phone: 951-674-9243
  • Fax: 951-674-9635
Mailing address:
  • Phone: 530-893-0758
  • Fax: 530-893-0502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGIE R WIECHERT
Title or Position: DIRECTOR OF FINANCIAL ANALYSIS
Credential:
Phone: 530-230-1210