Provider Demographics
NPI:1518304138
Name:VICTOR TREATMENT CENTER
Entity Type:Organization
Organization Name:VICTOR TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH REHAB SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIPERLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-291-8700
Mailing Address - Street 1:3164 CONDO CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3164 CONDO CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2557
Practice Address - Country:US
Practice Address - Phone:707-576-7218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children