Provider Demographics
NPI:1639674237
Name:ES SD VICTORIAN LLC
Entity Type:Organization
Organization Name:ES SD VICTORIAN LLC
Other - Org Name:THE VICTORIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:UHLIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-242-8300
Mailing Address - Street 1:2334 WASHINGTON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-2159
Mailing Address - Country:US
Mailing Address - Phone:530-242-8300
Mailing Address - Fax:
Practice Address - Street 1:1321 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-2505
Practice Address - Country:US
Practice Address - Phone:605-342-1913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-26
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD310400000XMedicaid