Provider Demographics
NPI:1609630276
Name:VICTORY BAY RESIDENTIAL SERVICES I, LLC
Entity Type:Organization
Organization Name:VICTORY BAY RESIDENTIAL SERVICES I, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LICENSING & COMPLIANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-282-2028
Mailing Address - Street 1:2940 SUMMIT ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3416
Mailing Address - Country:US
Mailing Address - Phone:856-282-2028
Mailing Address - Fax:
Practice Address - Street 1:19667 TRULL BROOK DR
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-5630
Practice Address - Country:US
Practice Address - Phone:856-282-2028
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service