Provider Demographics
NPI:1497007694
Name:VICTORY ADDICTION RECOVERY CENTER
Entity Type:Organization
Organization Name:VICTORY ADDICTION RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEGENDRE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:337-456-9111
Mailing Address - Street 1:111 LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6821
Mailing Address - Country:US
Mailing Address - Phone:337-456-9111
Mailing Address - Fax:337-456-9131
Practice Address - Street 1:111 LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6821
Practice Address - Country:US
Practice Address - Phone:337-456-9111
Practice Address - Fax:337-456-9131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-11
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA324500000X
LA2203781178324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility