Provider Demographics
NPI:1467896407
Name:VICTORIA PRESONAL CARE HOME LLC
Entity Type:Organization
Organization Name:VICTORIA PRESONAL CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:GIBSON
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-785-6600
Mailing Address - Street 1:2666 NANCY DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-4941
Mailing Address - Country:US
Mailing Address - Phone:478-785-6600
Mailing Address - Fax:
Practice Address - Street 1:2666 NANCY DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-4941
Practice Address - Country:US
Practice Address - Phone:478-785-6600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH006424310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility