Provider Demographics
NPI:1164589321
Name:VICTORY HOME HEALTH AGENCY
Entity Type:Organization
Organization Name:VICTORY HOME HEALTH AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JECINTA
Authorized Official - Middle Name:NKEIRUKA
Authorized Official - Last Name:AZONOBI
Authorized Official - Suffix:
Authorized Official - Credentials:LVN
Authorized Official - Phone:951-924-5114
Mailing Address - Street 1:24490 SUNNYMEAD BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-7762
Mailing Address - Country:US
Mailing Address - Phone:951-924-5114
Mailing Address - Fax:951-924-5182
Practice Address - Street 1:24490 SUNNYMEAD BLVD STE 108
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-7762
Practice Address - Country:US
Practice Address - Phone:951-924-5114
Practice Address - Fax:951-924-5182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHHA08190FMedicaid
CA058190Medicare ID - Type UnspecifiedHOME HEALTH CARE