Provider Demographics
NPI:1750947743
Name:MAKORI, VICTOR G
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:G
Last Name:MAKORI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17017 GEORGETOWN WAY
Mailing Address - Street 2:
Mailing Address - City:ROSEMOUNT
Mailing Address - State:MN
Mailing Address - Zip Code:55068-5159
Mailing Address - Country:US
Mailing Address - Phone:612-290-9608
Mailing Address - Fax:
Practice Address - Street 1:17017 GEORGETOWN WAY
Practice Address - Street 2:
Practice Address - City:ROSEMOUNT
Practice Address - State:MN
Practice Address - Zip Code:55068-5159
Practice Address - Country:US
Practice Address - Phone:612-290-9608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2300Medicaid