Provider Demographics
NPI:1598537920
Name:ILLUMINATING VICTORY
Entity Type:Organization
Organization Name:ILLUMINATING VICTORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER-GRAVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-984-3838
Mailing Address - Street 1:PO BOX 11701
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-0701
Mailing Address - Country:US
Mailing Address - Phone:614-984-3838
Mailing Address - Fax:
Practice Address - Street 1:976 N NELSON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-2608
Practice Address - Country:US
Practice Address - Phone:614-984-3838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
No305S00000XManaged Care OrganizationsPoint of Service
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care