Provider Demographics
NPI:1720458300
Name:VICTORY THROUGH FAITH RECOVERY SERVIES
Entity Type:Organization
Organization Name:VICTORY THROUGH FAITH RECOVERY SERVIES
Other - Org Name:THE MICAH HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-314-2460
Mailing Address - Street 1:1523 NICOLLET AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-2723
Mailing Address - Country:US
Mailing Address - Phone:612-314-2460
Mailing Address - Fax:612-871-4290
Practice Address - Street 1:1523 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-2723
Practice Address - Country:US
Practice Address - Phone:612-314-2460
Practice Address - Fax:612-871-4290
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VICTORY THROUGH FAITH RECOVERY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1069387251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health