Provider Demographics
NPI:1366199408
Name:ARCH-VICTORVILLE LLC
Entity type:Organization
Organization Name:ARCH-VICTORVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-885-7114
Mailing Address - Street 1:15000 7TH STREET
Mailing Address - Street 2:STE 200
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395
Mailing Address - Country:US
Mailing Address - Phone:442-235-3448
Mailing Address - Fax:
Practice Address - Street 1:15000 7TH STREET
Practice Address - Street 2:STE 200
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395
Practice Address - Country:US
Practice Address - Phone:760-885-7114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-08
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty