Provider Demographics
NPI:1407356751
Name:VICTORY CMH CORP
Entity Type:Organization
Organization Name:VICTORY CMH CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADOLFO
Authorized Official - Middle Name:L
Authorized Official - Last Name:NUNEZ RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-380-9733
Mailing Address - Street 1:2099 W 76TH ST UNIT 13
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-1834
Mailing Address - Country:US
Mailing Address - Phone:786-380-9733
Mailing Address - Fax:
Practice Address - Street 1:2099 W 76TH ST UNIT 13
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33016-1834
Practice Address - Country:US
Practice Address - Phone:786-380-9733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)