Provider Demographics
NPI:1639843279
Name:VICTORY GROUP HOME LLC
Entity Type:Organization
Organization Name:VICTORY GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:EVELYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUSABE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-648-8397
Mailing Address - Street 1:9127 W MINNEZONA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-2446
Mailing Address - Country:US
Mailing Address - Phone:469-648-8397
Mailing Address - Fax:
Practice Address - Street 1:9127 W MINNEZONA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2446
Practice Address - Country:US
Practice Address - Phone:469-648-8397
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH6785OtherBH LICENSE