NPIMap

Organization Active NPI

Victory Clinical Services II LLC

  • Addiction Medicine (Family Medicine) Physician
  • South Bend, IN
National Provider Identifier
1497798284
Registry record updated Mar 22, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Addiction Medicine (Family Medicine) PhysicianTaxonomy code 207QA0401X
License
02001493A Issued in IN
Legal business name
VICTORY CLINICAL SERVICES II LLC
Practice address
4218 W Western Ave
South Bend, IN 46619-2622
Phone
(574) 233-1524
Fax
(574) 233-1612
NPI assigned
Jun 13, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 22, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. David Blankenship
Title
Administrative Director
Phone
(574) 233-1524

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Health Service PsychologistGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 103TH0100X 20010221A IN
Addiction Medicine (Family Medicine) PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207QA0401X 02001493A IN Primary
Nurse PractitionerGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 363L00000X 71001833A IN

Addresses

Primary practice location

4218 W Western Ave
South Bend, IN 46619-2622

Mailing address

4218 W Western Ave
South Bend, IN 46619-2622
Phone (574) 233-1524

Other identifiers 6

IdentifierTypeStateIssuer
1255432233OtherINWOODWARD NPC - NPI
168750MedicaidIN
100220790MedicaidIN
200495610MedicaidIN
1518055565OtherINSHEEHAN HSPP - NPI
1982647434OtherINWANG - NPI

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in IN
Opioid treatment program
Medicare-enrolled since Jan 1, 2020

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200117001513 IN Part B Supplier - Opioid Treatment Program (Otp) 5193150274 Practice locations: South Bend, IN

National Provider Directory

National Provider Directory

Locations

4218 W Western Ave
South Bend, IN 46619
Phone (574) 233-1524

Practitioners & affiliated clinicians

Practitioners 14

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1150156800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1332374400000",
    "number": "1497798284",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4218 W WESTERN AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466192622",
            "telephone_number": "574-233-1524",
            "fax_number": "574-233-1612"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4218 W WESTERN AVE",
            "city": "SOUTH BEND",
            "state": "IN",
            "postal_code": "466192622",
            "telephone_number": "574-233-1524",
            "fax_number": "574-233-1612"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VICTORY CLINICAL SERVICES II LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-06-13",
        "last_updated": "2012-03-22",
        "status": "A",
        "authorized_official_last_name": "BLANKENSHIP",
        "authorized_official_first_name": "DAVID",
        "authorized_official_title_or_position": "ADMINISTRATIVE DIRECTOR",
        "authorized_official_telephone_number": "574-233-1524",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "103TH0100X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Psychologist, Health Service",
            "state": "IN",
            "license": "20010221A",
            "primary": false
        },
        {
            "code": "207QA0401X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine, Addiction Medicine",
            "state": "IN",
            "license": "02001493A",
            "primary": true
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": "IN",
            "license": "71001833A",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WOODWARD NPC - NPI",
            "identifier": "1255432233",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "168750",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100220790",
            "state": "IN"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200495610",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SHEEHAN HSPP - NPI",
            "identifier": "1518055565",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "WANG - NPI",
            "identifier": "1982647434",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Bend, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.