Provider Demographics
NPI:1710180955
Name:VICTORIAN SQUARE, LLC
Entity Type:Organization
Organization Name:VICTORIAN SQUARE, LLC
Other - Org Name:VICTORIAN SQUARE ASSISTED LIVING FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:BELLANDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-228-8131
Mailing Address - Street 1:12933 W HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9107
Mailing Address - Country:US
Mailing Address - Phone:502-228-8131
Mailing Address - Fax:502-228-1940
Practice Address - Street 1:241 S CHAMBERLAIN AVE
Practice Address - Street 2:
Practice Address - City:ROCKWOOD
Practice Address - State:TN
Practice Address - Zip Code:37854-6542
Practice Address - Country:US
Practice Address - Phone:865-354-1133
Practice Address - Fax:865-354-6371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL00000001473104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4262690OtherTENNCARE/MEDICAID