Provider Demographics
NPI:1457822413
Name:VICTA LLC
Entity Type:Organization
Organization Name:VICTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOYAN
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, LCDP
Authorized Official - Phone:401-300-5757
Mailing Address - Street 1:110 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-2423
Mailing Address - Country:US
Mailing Address - Phone:401-300-5757
Mailing Address - Fax:401-300-5656
Practice Address - Street 1:110 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2423
Practice Address - Country:US
Practice Address - Phone:401-300-5757
Practice Address - Fax:401-300-5656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1104317007Medicaid