Provider Demographics
NPI:1215579628
Name:VICTOR COMMUNITY SUPPORT SERVICES, INC.
Entity Type:Organization
Organization Name:VICTOR COMMUNITY SUPPORT SERVICES, INC.
Other - Org Name:VICTOR COMMUNITY SUPPORT SERVICES, MANTECA
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL ANALYSIS
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 1:1360 E LASSEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-7823
Mailing Address - Country:US
Mailing Address - Phone:530-893-0758
Mailing Address - Fax:530-893-0502
Practice Address - Street 1:302 CHERRY LN
Practice Address - Street 2:SUITES 101, 201 & 208
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4311
Practice Address - Country:US
Practice Address - Phone:209-647-6200
Practice Address - Fax:209-647-6210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-17
Last Update Date:2023-12-04
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 NUMBER