Provider Demographics
NPI:1558500181
Name:VIC MEDICAL SERVICES INC
Entity type:Organization
Organization Name:VIC MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:IKE
Authorized Official - Middle Name:F
Authorized Official - Last Name:UDENGWU
Authorized Official - Suffix:SR
Authorized Official - Credentials:PA
Authorized Official - Phone:310-493-9393
Mailing Address - Street 1:13658 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5824
Mailing Address - Country:US
Mailing Address - Phone:310-219-0212
Mailing Address - Fax:
Practice Address - Street 1:13658 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5824
Practice Address - Country:US
Practice Address - Phone:310-219-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children