Provider Demographics
NPI:1912409137
Name:VICTORY VILLAGE
Entity Type:Organization
Organization Name:VICTORY VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CRIDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-735-2219
Mailing Address - Street 1:3650 SALEM CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:GA
Mailing Address - Zip Code:30143-5288
Mailing Address - Country:US
Mailing Address - Phone:770-735-2219
Mailing Address - Fax:770-828-0698
Practice Address - Street 1:3650 SALEM CHURCH RD
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:GA
Practice Address - Zip Code:30143-5288
Practice Address - Country:US
Practice Address - Phone:770-735-2219
Practice Address - Fax:770-828-0698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-03
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCH008447310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility