Healthcare Provider Details

I. General information

NPI: 1922249440
Provider Name (Legal Business Name): VICTORY CLINICAL SERVICES IV, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 SHATTUCK RD
SAGINAW MI
48604-2329
US

IV. Provider business mailing address

508 SHATTUCK RD
SAGINAW MI
48604-2329
US

V. Phone/Fax

Practice location:
  • Phone: 989-754-7867
  • Fax:
Mailing address:
  • Phone: 989-754-7867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number730208
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number730208
License Number StateMI

VIII. Authorized Official

Name: MR. DAVID BLANKENSHIP
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 989-754-7867