Provider Demographics
NPI:1629277223
Name:THE VICTORIAN ASSISTED LIVING HOME
Entity Type:Organization
Organization Name:THE VICTORIAN ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAVON
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HUNEKE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:605-342-1913
Mailing Address - Street 1:1321 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-2524
Mailing Address - Country:US
Mailing Address - Phone:605-342-1913
Mailing Address - Fax:605-348-2870
Practice Address - Street 1:1321 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2524
Practice Address - Country:US
Practice Address - Phone:605-342-1913
Practice Address - Fax:605-348-2870
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11035310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9570740Medicaid