Basic Information
| Provider Information | |||||||||
| NPI: | 1922306620 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VICTOR COMMUNITY SUPPORT SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VICTOR COMMUNITY SUPPORT SERVICES, PERRIS | ||||||||
| 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: | 555 N PERRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | PERRIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925712811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9514365300 | ||||||||
| FaxNumber: | 9514365350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2011 | ||||||||
| LastUpdateDate: | 05/20/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIECHERT | ||||||||
| AuthorizedOfficialFirstName: | ANGIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF FINANCIAL PLANNING | ||||||||
| AuthorizedOfficialTelephone: | 5032301210 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 01042 | 01 | CA | LEGAL ENTITY # | OTHER |