Provider Demographics
NPI:1750036893
Name:VICTORIOUS MENTAL HEALTHCARE LLC
Entity Type:Organization
Organization Name:VICTORIOUS MENTAL HEALTHCARE LLC
Other - Org Name:VICTORIOUS PRP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOSEDE
Authorized Official - Middle Name:O
Authorized Official - Last Name:ADETUNJI IDOWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-540-0338
Mailing Address - Street 1:2901 DRUID PARK DR STE A202
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-8131
Mailing Address - Country:US
Mailing Address - Phone:410-488-5171
Mailing Address - Fax:410-488-5173
Practice Address - Street 1:2901 DRUID PARK DR STE A202
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-8131
Practice Address - Country:US
Practice Address - Phone:410-488-5171
Practice Address - Fax:410-488-5173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)