=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497542393
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTOR COMMUNITY SUPPORT SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 325 W HOSPITALITY LN STE 112
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92408-3211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-522-4656
-----------------------------------------------------
Fax | 909-763-5525
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1360 E LASSEN AVE
-----------------------------------------------------
City | CHICO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95973-7823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-893-0758
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF FINANCIAL ANALYSIS
-----------------------------------------------------
Name | ANGIE R WIECHERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 530-230-1210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------