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General NPI Number Information
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NPI Number | 1922249440
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Entity Type | Organization
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Legal Business Name | VICTORY CLINICAL SERVICES IV, LLC
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Dates
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Enumeration Date | 03/12/2009
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Last Update Date | 03/12/2009
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Provider Practice Location Address
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Address Line | 508 SHATTUCK RD
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City | SAGINAW
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State | MI
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Zip | 48604-2329
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Country | US
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Telephone | 989-754-7867
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Fax |
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Provider Business Mailing Address
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Address Line | 508 SHATTUCK RD
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City | SAGINAW
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State | MI
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Zip | 48604-2329
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Country | US
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Telephone | 989-754-7867
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MR. DAVID BLANKENSHIP
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Credential |
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Telephone | 989-754-7867
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 730208
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 261QM2800X
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Taxonomy Name | Methadone Clinic
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License Number | 730208
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License Number State | MI
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