Basic Information
| Provider Information | |||||||||
| NPI: | 1215579628 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTOR COMMUNITY SUPPORT SERVICES, INC. | ||||||||
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| OtherOrganizationName: | VICTOR COMMUNITY SUPPORT SERVICES, MANTECA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1360 E LASSEN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959737823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308930758 | ||||||||
| FaxNumber: | 5308930502 | ||||||||
| Practice Location | |||||||||
| Address1: | 302 CHERRY LN STE 101&201 | ||||||||
| Address2: | |||||||||
| City: | MANTECA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953374311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2096476200 | ||||||||
| FaxNumber: | 2096476210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2019 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIECHERT | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCIAL ANALYSIS | ||||||||
| AuthorizedOfficialTelephone: | 5302301210 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 01042 | 01 | CA | LEGAL ENTITY NUMBER | OTHER |