Provider Demographics
NPI:1861627507
Name:VICTORY CLINICAL SERVICES LANSING
Entity Type:Organization
Organization Name:VICTORY CLINICAL SERVICES LANSING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BLANKENSHIP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-394-7867
Mailing Address - Street 1:4902 S CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-5474
Mailing Address - Country:US
Mailing Address - Phone:517-394-7867
Mailing Address - Fax:517-394-7869
Practice Address - Street 1:4902 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-5474
Practice Address - Country:US
Practice Address - Phone:517-394-7867
Practice Address - Fax:517-394-7869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-26
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI330330261QM0850X, 261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI 10046MOtherOTP - SAMHSA #