Provider Demographics
NPI:1346576105
Name:MONCHILOV, VICTORIA M
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:M
Last Name:MONCHILOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6314 COUNTY ROAD 16
Mailing Address - Street 2:
Mailing Address - City:BUTLER
Mailing Address - State:IN
Mailing Address - Zip Code:46721-9657
Mailing Address - Country:US
Mailing Address - Phone:260-868-0507
Mailing Address - Fax:260-868-0507
Practice Address - Street 1:6314 COUNTY ROAD 16
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:IN
Practice Address - Zip Code:46721-9657
Practice Address - Country:US
Practice Address - Phone:260-868-0507
Practice Address - Fax:260-868-0507
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-28
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200954290Medicaid