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General NPI Number Information
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NPI Number | 1396478707
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Entity Type | Organization
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Legal Business Name | VICI PERFORMANCE LLC
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Dates
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Enumeration Date | 07/03/2022
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Last Update Date | 07/10/2022
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Provider Practice Location Address
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Address Line | 28631 CANWOOD ST
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City | AGOURA HILLS
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State | CA
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Zip | 91301-3213
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Country | US
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Telephone | 818-923-7555
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Fax |
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Provider Business Mailing Address
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Address Line | 28631 CANWOOD ST
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City | AGOURA HILLS
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State | CA
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Zip | 91301-3213
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Country | US
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Telephone | 818-923-7555
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Fax |
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Authorized Official
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Title or Position | FOUNDER
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Name | RAUL MIRANDA
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Credential |
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Telephone | 805-760-2700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0800X
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Taxonomy Name | Recovery Care Clinic/Center
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License Number |
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License Number State |
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