Provider Demographics
NPI:1972121192
Name:VICTORIAN MANOR, INC.
Entity Type:Organization
Organization Name:VICTORIAN MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ONWNER
Authorized Official - Prefix:
Authorized Official - First Name:NOEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-236-4300
Mailing Address - Street 1:15140 SW 38TH ST
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-2755
Mailing Address - Country:US
Mailing Address - Phone:954-816-3203
Mailing Address - Fax:
Practice Address - Street 1:11150 SW 42ND CT
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2140
Practice Address - Country:US
Practice Address - Phone:954-236-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities