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General NPI Number Information
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NPI Number | 1184377236
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Entity Type | Organization
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Legal Business Name | VICTORY CARE CLINIC
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Dates
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Enumeration Date | 01/29/2022
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Last Update Date | 11/12/2022
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Provider Practice Location Address
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Address Line | 5189 VENOY RD
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City | WAYNE
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State | MI
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Zip | 48184-2545
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Country | US
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Telephone | 734-259-4579
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Fax |
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Provider Business Mailing Address
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Address Line | 3876 ELDER RD S
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48324-2537
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Country | US
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Telephone | 313-729-0016
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. OSAMUEDEMEN IYOHA
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Credential | MD
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Telephone | 313-729-0016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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