Provider Demographics
NPI:1306172747
Name:VICTORY HEALTH CARE AGENCY LLC
Entity type:Organization
Organization Name:VICTORY HEALTH CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:313-882-3303
Mailing Address - Street 1:5555 CONNER AVE
Mailing Address - Street 2:SUITE 3247
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213
Mailing Address - Country:US
Mailing Address - Phone:313-882-3303
Mailing Address - Fax:313-571-3304
Practice Address - Street 1:5555 CONNER AVE
Practice Address - Street 2:SUITE 3247
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213
Practice Address - Country:US
Practice Address - Phone:313-882-3303
Practice Address - Fax:313-571-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI35304347C00000X, 320800000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No347C00000XTransportation ServicesPrivate Vehicle
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness