Provider Demographics
NPI:1114229630
Name:VICTORY NURSING & HOME CARE, INC.
Entity Type:Organization
Organization Name:VICTORY NURSING & HOME CARE, INC.
Other - Org Name:VICTORY STAFFING & HOME CARE SERVICES, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEONA
Authorized Official - Middle Name:N
Authorized Official - Last Name:AMADI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-474-8900
Mailing Address - Street 1:238 S. CARROLL RD.
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1929
Mailing Address - Country:US
Mailing Address - Phone:404-474-8900
Mailing Address - Fax:404-474-1189
Practice Address - Street 1:238 S CARROLL RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-2625
Practice Address - Country:US
Practice Address - Phone:404-474-8900
Practice Address - Fax:404-474-1189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-04
Last Update Date:2017-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022-R-0503253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA275601989AMedicaid