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General NPI Number Information
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NPI Number | 1497798284
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Entity Type | Organization
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Legal Business Name | VICTORY CLINICAL SERVICES II LLC
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Dates
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Enumeration Date | 06/13/2006
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Last Update Date | 03/22/2012
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Provider Practice Location Address
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Address Line | 4218 W WESTERN AVE
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City | SOUTH BEND
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State | IN
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Zip | 46619-2622
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Country | US
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Telephone | 574-233-1524
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Fax | 574-233-1612
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Provider Business Mailing Address
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Address Line | 4218 W WESTERN AVE
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City | SOUTH BEND
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State | IN
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Zip | 46619-2622
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Country | US
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Telephone | 574-233-1524
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Fax | 574-233-1612
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Authorized Official
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Title or Position | ADMINISTRATIVE DIRECTOR
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Name | MR. DAVID BLANKENSHIP
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Credential |
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Telephone | 574-233-1524
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TH0100X
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Taxonomy Name | Health Service Psychologist
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License Number | 20010221A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 71001833A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 207QA0401X
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Taxonomy Name | Addiction Medicine (Family Medicine) Physician
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License Number | 02001493A
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License Number State | IN
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