=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518502764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORY AID LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2019
-----------------------------------------------------
Last Update Date | 12/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 DOMESSINA LN APT F7
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07006-4850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-703-8180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 DOMESSINA LN APT F7
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07006-4850
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 862-703-8180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SUPERVISOR
-----------------------------------------------------
Name | MATTHEW M. NICASTRO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 862-703-8180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------