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VICTORY CARE CLINIC
Complete NPI Record 1770291791
Clinic/Center - Adult Mental Health in Wayne, MI

NPI Status: Active since November 08, 2022

Contact Information

5189 VENOY RD
WAYNE, MI
ZIP 48184
Phone: (734) 331-2088

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Business Mailing Address City Name
  7. Provider Business Mailing Address State Name
  8. Provider Business Mailing Address Postal Code
  9. Provider Business Mailing Address Country Code If outside U S
  10. Provider First Line Business Practice Location Address
  11. Provider Business Practice Location Address City Name
  12. Provider Business Practice Location Address State Name
  13. Provider Business Practice Location Address Postal Code
  14. Provider Business Practice Location Address Country Code If outside U S
  15. Provider Business Practice Location Address Telephone Number
  16. Provider Enumeration Date
  17. Last Update Date
  18. Authorized Official Last Name
  19. Authorized Official First Name
  20. Authorized Official Title or Position
  21. Authorized Official Telephone Number
  22. Healthcare Provider Taxonomy Code 1
  23. Healthcare Provider Primary Taxonomy Switch 1
  24. Is Organization Subpart
  25. Authorized Official Name Prefix Text
  26. Authorized Official Credential Text
  27. NPI Certification Date

Complete NPI Dataset

This page represents the complete record for NPI 1770291791. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1770291791
The first name of the provider, if the provider is an individual.
Entity Type Code: 2
The middle name of the provider, if the provider is an individual.
Employer Identification Number EIN: UNAVAIL
The name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
Provider First Line Business Mailing Address: 3876 ELDER RD S
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Mailing Address City Name: WEST BLOOMFIELD
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: MI
The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address State name’’.
Provider Business Mailing Address Postal Code: 483242537
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider First Line Business Practice Location Address: 5189 VENOY RD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: WAYNE
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: MI
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 481842545
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
Provider Business Practice Location Address Country Code If outside U S : US
The country code in the location address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 7343312088
The telephone number associated with the location address of the provider being identified.
Provider Enumeration Date: 11/8/2022
The telephone number associated with the location address of the provider being identified.
Last Update Date: 11/8/2022
The fax number associated with the location address of the provider being identified.
Authorized Official Last Name: IYOHA
The date the provider was assigned a unique identifier (assigned an NPI).
Authorized Official First Name: OSAMUEDEMEN
The date that a record was last updated or changed.
Authorized Official Title or Position: OWNER
The code designating the provider’s gender if the provider is a person.
Authorized Official Telephone Number: 7343312088
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Taxonomy Code 1: 261QM0850X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Healthcare Provider Primary Taxonomy Switch 1: Y
Is Organization Subpart: N
Authorized Official Name Prefix Text: DR.
Authorized Official Credential Text: MD
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
NPI Certification Date: 11/4/2022