Provider Demographics
NPI:1972978716
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:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BODE
Authorized Official - Middle Name:
Authorized Official - Last Name:AKADRI
Authorized Official - Suffix:
Authorized Official - Credentials:MMHC
Authorized Official - Phone:443-204-5144
Mailing Address - Street 1:5808 YORK RD FL 2
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3624
Mailing Address - Country:US
Mailing Address - Phone:443-204-5144
Mailing Address - Fax:410-617-8478
Practice Address - Street 1:5808 YORK RD FL 2
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3624
Practice Address - Country:US
Practice Address - Phone:443-204-5144
Practice Address - Fax:410-617-8478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-04
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDMH-1778251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD=========Medicaid