VICTORY CLINICAL SERVICES II LLC

Provider Demographics

• NPI: 1497798284
• Name: VICTORY CLINICAL SERVICES II LLC
• Entity Type: Organization
• Organization Name: VICTORY CLINICAL SERVICES II LLC
• Authorized Official - Title/Position: ADMINISTRATIVE DIRECTOR
• Authorized Official - Prefix: MR
• Authorized Official - First Name: DAVID
• Authorized Official - Last Name: BLANKENSHIP
• Authorized Official - Phone: 574-233-1524
• Mailing Address - Street 1: 4218 W WESTERN AVE
• Mailing Address - City: SOUTH BEND
• Mailing Address - State: IN
• Mailing Address - Zip Code: 46619-2622
• Mailing Address - Country: US
• Mailing Address - Phone: 574-233-1524
• Mailing Address - Fax: 574-233-1612
• Practice Address - Street 1: 4218 W WESTERN AVE
• Practice Address - City: SOUTH BEND
• Practice Address - State: IN
• Practice Address - Zip Code: 46619-2622
• Practice Address - Country: US
• Practice Address - Phone: 574-233-1524
• Practice Address - Fax: 574-233-1612
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2006-06-13
• Last Update Date: 2012-03-22

Provider Licenses

State	License ID	Taxonomies
IN	20010221A	103TH0100X
IN	02001493A	207QA0401X
IN	71001833A	363L00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207QA0401X	Allopathic & Osteopathic Physicians	Family Medicine	Addiction Medicine	Group - Single Specialty
No	103TH0100X	Behavioral Health & Social Service Providers	Psychologist	Health Service	Group - Single Specialty
No	363L00000X	Physician Assistants & Advanced Practice Nursing Providers	Nurse Practitioner		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
IN	1255432233	Other	WOODWARD NPC - NPI
IN	168750	Medicaid
IN	100220790	Medicaid
IN	200495610	Medicaid
IN	1518055565	Other	SHEEHAN HSPP - NPI
IN	1982647434	Other	WANG - NPI
IN	168750	Medicaid
IN	5339542	Medicare UPIN
IN	090310	Medicare ID - Type Unspecified	SHEEHAN HSPP
IN	100220790	Medicaid
IN	200495610	Medicaid