Provider Demographics
NPI:1922249440
Name:VICTORY CLINICAL SERVICES IV, LLC
Entity Type:Organization
Organization Name:VICTORY CLINICAL SERVICES IV, LLC
Other - Org Name:VICTORY CLINIC IV
Other - Org Type:Other Name
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:989-754-7867
Mailing Address - Street 1:508 SHATTUCK RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2329
Mailing Address - Country:US
Mailing Address - Phone:989-754-7867
Mailing Address - Fax:
Practice Address - Street 1:508 SHATTUCK RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604-2329
Practice Address - Country:US
Practice Address - Phone:989-754-7867
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-12
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI730208261QM2800X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI10200MOtherOTP-SAMHSA ID