Organization
VICTORY CLINICAL SERVICES II LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. DAVID BLANKENSHIP (ADMINISTRATIVE DIRECTOR)
(574) 233-1524
Entity
Organization
Contact information
Practice address
4218 W WESTERN AVE, SOUTH BEND, IN 46619-2622
(574) 233-1524
(574) 233-1612
Mailing address
4218 W WESTERN AVE, SOUTH BEND, IN 46619-2622
(574) 233-1524
(574) 233-1612
Taxonomy
Speciality
Code
Description
License number
State
103TH0100X
Health Service Psychologist
20010221A
IN
207QA0401X
Addiction Medicine (Family Medicine) Physician
Primary
02001493A
IN
363L00000X
Nurse Practitioner
71001833A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100220790
—
IN
01
—
1255432233
WOODWARD NPC - NPI
IN
01
—
1518055565
SHEEHAN HSPP - NPI
IN
05
—
168750
—
IN
01
—
1982647434
WANG - NPI
IN
05
—
200495610
—
IN
Enumeration date
06/13/2006
Last updated
03/22/2012
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