Healthcare Provider Details

I. General information

NPI: 1609630276
Provider Name (Legal Business Name): VICTORY BAY RESIDENTIAL SERVICES I, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19667 TRULL BROOK DR
TARZANA CA
91356-5630
US

IV. Provider business mailing address

2940 SUMMIT ST STE 2D
OAKLAND CA
94609-3416
US

V. Phone/Fax

Practice location:
  • Phone: 856-282-2028
  • Fax:
Mailing address:
  • Phone: 856-282-2028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER MELLON
Title or Position: DIRECTOR REGULATORY COMPLIANCE
Credential:
Phone: 856-282-5590