Provider Demographics
NPI:1265593800
Name:VICTORY PARK HEALTHCARE GROUP, INC.
Entity type:Organization
Organization Name:VICTORY PARK HEALTHCARE GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:WEISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-292-5706
Mailing Address - Street 1:26691 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:BEDFORD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44146-1447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1578 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:OH
Practice Address - Zip Code:45212-2510
Practice Address - Country:US
Practice Address - Phone:216-292-5706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1309N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2703846Medicaid
36-5490Medicare ID - Type Unspecified