Healthcare Provider Details

I. General information

NPI: 1497798284
Provider Name (Legal Business Name): VICTORY CLINICAL SERVICES II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 W WESTERN AVE
SOUTH BEND IN
46619-2622
US

IV. Provider business mailing address

4218 W WESTERN AVE
SOUTH BEND IN
46619-2622
US

V. Phone/Fax

Practice location:
  • Phone: 574-233-1524
  • Fax: 574-233-1612
Mailing address:
  • Phone: 574-233-1524
  • Fax: 574-233-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number20010221A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71001833A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number02001493A
License Number StateIN

VIII. Authorized Official

Name: MR. DAVID BLANKENSHIP
Title or Position: ADMINISTRATIVE DIRECTOR
Credential:
Phone: 574-233-1524