Provider Demographics
NPI:1174510259
Name:VICTORY LAKE OPERATIONS, LLC
Entity Type:Organization
Organization Name:VICTORY LAKE OPERATIONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:845-229-9177
Mailing Address - Street 1:958 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-4257
Mailing Address - Country:US
Mailing Address - Phone:516-409-0700
Mailing Address - Fax:516-809-0161
Practice Address - Street 1:958 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4257
Practice Address - Country:US
Practice Address - Phone:516-409-0700
Practice Address - Fax:516-809-0161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00308961314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00308961Medicaid
NY00308961Medicaid
NY00308961Medicaid