Healthcare Provider Details

I. General information

NPI: 1447504782
Provider Name (Legal Business Name): VICTORIOUS HEALTHCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2012
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6512 SIX FORKS RD STE 200
RALEIGH NC
27615-6525
US

IV. Provider business mailing address

4225 COLDWATER SPRINGS DR
RALEIGH NC
27616-8419
US

V. Phone/Fax

Practice location:
  • Phone: 919-846-2111
  • Fax: 919-846-7733
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: BRUCE WARD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 919-523-2761