Healthcare Provider Details

I. General information

NPI: 1598537920
Provider Name (Legal Business Name): ILLUMINATING VICTORY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 10/30/2023
Certification Date: 10/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 N NELSON RD
COLUMBUS OH
43219-2608
US

IV. Provider business mailing address

PO BOX 11701
COLUMBUS OH
43211-0701
US

V. Phone/Fax

Practice location:
  • Phone: 614-984-3838
  • Fax:
Mailing address:
  • Phone: 614-984-3838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. TERRI CARTER-GRAVES
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 614-984-3838