Provider Demographics
NPI:1679739833
Name:VICTIRIAN ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:VICTIRIAN ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:STODDARDDANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-985-4791
Mailing Address - Street 1:4610 NW 113TH TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-1026
Mailing Address - Country:US
Mailing Address - Phone:772-985-4791
Mailing Address - Fax:
Practice Address - Street 1:4610 NW 113TH TER
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-1026
Practice Address - Country:US
Practice Address - Phone:772-985-4791
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11327310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility