Provider Demographics
NPI:1487431805
Name:VICTORY HEALTH HOME PLLC
Entity type:Organization
Organization Name:VICTORY HEALTH HOME PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IBUKUN
Authorized Official - Middle Name:
Authorized Official - Last Name:ODUTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:602-502-4872
Mailing Address - Street 1:3887 E CITRINE RD
Mailing Address - Street 2:
Mailing Address - City:SAN TAN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85143-5688
Mailing Address - Country:US
Mailing Address - Phone:602-502-4872
Mailing Address - Fax:
Practice Address - Street 1:3887 E CITRINE RD
Practice Address - Street 2:
Practice Address - City:SAN TAN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85143-5688
Practice Address - Country:US
Practice Address - Phone:602-502-4872
Practice Address - Fax:480-210-3563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251S00000XAgenciesCommunity/Behavioral Health