Provider Demographics
NPI:1487896924
Name:A VICTORIOUS HEALTH SERVICE
Entity type:Organization
Organization Name:A VICTORIOUS HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IKE
Authorized Official - Middle Name:
Authorized Official - Last Name:IFEDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-535-0995
Mailing Address - Street 1:3549 N SHARON AMITY RD STE 301
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-2975
Mailing Address - Country:US
Mailing Address - Phone:704-535-0995
Mailing Address - Fax:704-536-4373
Practice Address - Street 1:2025 EBENEZER RD STE J1
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1079
Practice Address - Country:US
Practice Address - Phone:803-980-0116
Practice Address - Fax:803-980-0117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCEN0925251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management