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General NPI Number Information
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NPI Number | 1205392677
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Entity Type | Organization
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Legal Business Name | VICTORY TOWN COMMUNITY FOUNDATION
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Dates
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Enumeration Date | 02/11/2019
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Last Update Date | 02/11/2019
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Provider Practice Location Address
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Address Line | 5200 PHILADELPHIA DR
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City | DAYTON
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State | OH
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Zip | 45415-3608
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Country | US
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Telephone | 937-979-1699
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Fax |
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Provider Business Mailing Address
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Address Line | 3375 W SIEBENTHALER AVE
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City | DAYTON
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State | OH
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Zip | 45406-1827
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Country | US
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Telephone | 937-789-6792
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. CORNELUS M HAGANS
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Credential |
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Telephone | 937-789-6792
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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