MEDICARE: VICTOR COMMUNITY SUPPORT SERVICES, INC.

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
1	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01042	OTHER	CA	LEGAL ENTITY #

General Provider Information

NPI Number	:	1629240270
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTOR COMMUNITY SUPPORT SERVICES, INC.

Provider Business Mailing Address
First Line	:	1360 E LASSEN AVE
Second Line	:
City	:	CHICO
State	:	CA
Zip	:	95973-7823
Country	:	US
Telephone Number	:	530-893-0758
Fax Number	:	530-893-0502

Provider Business Practice Location Address
First Line	:	555 N PERRIS BLVD BLDG A
Second Line	:
City	:	PERRIS
State	:	CA
Zip	:	92571-2811
Country	:	US
Telephone Number	:	951-436-5300
Fax Number	:	951-436-5350

Authorized Official
Title or Position	:	MANGER OF FINANCIAL PLANNING
Name	:	MS. ANGIE R WIECHERT
Credential	:
Telephone Number	:	530-230-1210

Provider Enumeration Date	:	03/24/2008
Last Update Date	:	08/29/2013

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