Provider Demographics
NPI:1003314428
Name:VICTORY MANOR LLC.
Entity Type:Organization
Organization Name:VICTORY MANOR LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JUSTER
Authorized Official - Middle Name:MUTHONI
Authorized Official - Last Name:NJUGUNA
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:480-277-3995
Mailing Address - Street 1:1452 W MORELOS ST
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-7241
Mailing Address - Country:US
Mailing Address - Phone:480-277-3995
Mailing Address - Fax:
Practice Address - Street 1:1041 S YUCCA PL
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-0982
Practice Address - Country:US
Practice Address - Phone:480-277-3995
Practice Address - Fax:480-257-3447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH5323320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness