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NPI Code Detail

MEDICARE: VICTORIOUS LIFESTYLE LLC

MEDICARE: VICTORIOUS LIFESTYLE LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QM0850XAdult Mental Health Clinic/Center
2261QM0801XMental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number : 1457069338
Entity Type Code : Organization
Provider Name (Legal Business Name) : VICTORIOUS LIFESTYLE LLC
Provider Business Mailing Address
First Line : 1831 E APACHE BLVD APT 2098
Second Line :
City : TEMPE
State : AZ
Zip : 85281-6682
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 10000 N 31ST AVE STE C307
Second Line :
City : PHOENIX
State : AZ
Zip : 85051-9569
Country : US
Telephone Number : 240-397-0554
Fax Number :
Authorized Official
Title or Position : OWNER
Name : SHAREKA SHERROD
Credential :
Telephone Number : 240-397-0554
Provider Enumeration Date : 11/09/2022
Last Update Date : 11/09/2022

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Directions to “VICTORIOUS LIFESTYLE LLC ” Practice Location

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