Provider Demographics
NPI:1003114810
Name:VICTOR COMMUNITY SUPPORT SERVICES, INC
Entity Type:Organization
Organization Name:VICTOR COMMUNITY SUPPORT SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIECHERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-230-1210
Mailing Address - Street 1:PO BOX 5361
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95927-5361
Mailing Address - Country:US
Mailing Address - Phone:530-893-0758
Mailing Address - Fax:530-893-0502
Practice Address - Street 1:1545 S HOLT RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95206-9618
Practice Address - Country:US
Practice Address - Phone:209-969-5258
Practice Address - Fax:530-230-1265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01042OtherLEGAL ENTITY #