Provider Demographics
NPI:1588801294
Name:VICTORY HOUSE
Entity Type:Organization
Organization Name:VICTORY HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARTINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:UKATTAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-294-4966
Mailing Address - Street 1:804 QUAIL COVE CT
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8082
Mailing Address - Country:US
Mailing Address - Phone:336-292-7688
Mailing Address - Fax:336-851-6725
Practice Address - Street 1:804 QUAIL COVE CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-8082
Practice Address - Country:US
Practice Address - Phone:336-292-7688
Practice Address - Fax:336-851-6725
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STAR CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-876322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children