Provider Demographics
NPI:1396420469
Name:VICTORY RESIDENTIAL CORPORATION
Entity type:Organization
Organization Name:VICTORY RESIDENTIAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:XAVIER
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-636-3194
Mailing Address - Street 1:1566 E JEANNE LN
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-4046
Mailing Address - Country:US
Mailing Address - Phone:612-636-3194
Mailing Address - Fax:
Practice Address - Street 1:1566 E JEANNE LN
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85140-4046
Practice Address - Country:US
Practice Address - Phone:612-636-3194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-16
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty