Provider Demographics
NPI:1821172008
Name:VICTORIAN CARE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:VICTORIAN CARE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:NWACHUKWU
Authorized Official - Middle Name:A
Authorized Official - Last Name:ANAKWENZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-677-4600
Mailing Address - Street 1:PO BOX 88939
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90009-6939
Mailing Address - Country:US
Mailing Address - Phone:310-677-4600
Mailing Address - Fax:310-914-9705
Practice Address - Street 1:11149 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90303-2338
Practice Address - Country:US
Practice Address - Phone:310-677-4600
Practice Address - Fax:310-677-4600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAW9384207R00000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G506070Medicaid
CAA51749Medicare UPIN
CA00G506070Medicaid