Provider Demographics
NPI:1063910859
Name:VICTORY HEALTH CARE SERVICES LLC
Entity type:Organization
Organization Name:VICTORY HEALTH CARE SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BODE
Authorized Official - Middle Name:
Authorized Official - Last Name:AKADRI
Authorized Official - Suffix:
Authorized Official - Credentials:BED, MMP
Authorized Official - Phone:443-204-5144
Mailing Address - Street 1:1900 E NORTHERN PKWY STE 205207
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21239-2113
Mailing Address - Country:US
Mailing Address - Phone:443-204-5144
Mailing Address - Fax:410-617-8478
Practice Address - Street 1:499C BEAUMONT AVENUE
Practice Address - Street 2:SUITE 18
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212
Practice Address - Country:US
Practice Address - Phone:443-204-5144
Practice Address - Fax:667-212-2430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-26
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD666466100Medicaid
MD1972978716Medicaid