Provider Demographics
NPI:1407445638
Name:VICTORY, CONNER
Entity Type:Individual
Prefix:
First Name:CONNER
Middle Name:
Last Name:VICTORY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1719 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:EAST CHINA
Mailing Address - State:MI
Mailing Address - Zip Code:48054-1592
Mailing Address - Country:US
Mailing Address - Phone:586-940-4920
Mailing Address - Fax:
Practice Address - Street 1:24445 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6501
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator