Basic Information
| Provider Information | |||||||||
| NPI: | 1366806358 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTORY LIFE HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE BRIDGE INTO WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6221 ROUTE 474 | ||||||||
| Address2: | |||||||||
| City: | ASHVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147109788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167824158 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 95 E HIGH ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | WAYNESBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 153701853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7164561225 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2016 | ||||||||
| LastUpdateDate: | 04/06/2016 | ||||||||
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| AuthorizedOfficialLastName: | TERRY | ||||||||
| AuthorizedOfficialFirstName: | MARISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7164561225 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0401X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine |
No ID Information.