Provider Demographics
NPI:1770291791
Name:VICTORY CARE CLINIC
Entity type:Organization
Organization Name:VICTORY CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAMUEDEMEN
Authorized Official - Middle Name:
Authorized Official - Last Name:IYOHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:734-331-2088
Mailing Address - Street 1:3876 ELDER RD S
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-2537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5189 VENOY RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2545
Practice Address - Country:US
Practice Address - Phone:734-331-2088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health