Provider Demographics
NPI:1275850869
Name:VICTORY MOUNTAIN, INC.
Entity Type:Organization
Organization Name:VICTORY MOUNTAIN, INC.
Other - Org Name:VICTORY MOUNTAIN BOYS RANCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:SHAWN
Authorized Official - Last Name:SKINNER
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC
Authorized Official - Phone:573-546-7592
Mailing Address - Street 1:148 BOWLING LN
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MO
Mailing Address - Zip Code:63650-4148
Mailing Address - Country:US
Mailing Address - Phone:573-546-7592
Mailing Address - Fax:573-546-0125
Practice Address - Street 1:148 BOWLING LN
Practice Address - Street 2:
Practice Address - City:IRONTON
Practice Address - State:MO
Practice Address - Zip Code:63650-4148
Practice Address - Country:US
Practice Address - Phone:573-546-7592
Practice Address - Fax:573-546-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-22
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO001770712322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children