Provider Demographics
| NPI: | 1912455361 |
|---|---|
| Name: | VICTORIOUS HEALTHCARE L.L.C. |
| Entity Type: | Organization |
| Organization Name: | VICTORIOUS HEALTHCARE L.L.C. |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | C.E. O. |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | MARY |
| Authorized Official - Middle Name: | JEAN |
| Authorized Official - Last Name: | BEN |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 601-209-4278 |
| Mailing Address - Street 1: | 4959 LAUREL OAK DR |
| Mailing Address - Street 2: | |
| Mailing Address - City: | JACKSON |
| Mailing Address - State: | MS |
| Mailing Address - Zip Code: | 39212-2150 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 601-209-4278 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 4959 LAUREL OAK DR |
| Practice Address - Street 2: | |
| Practice Address - City: | JACKSON |
| Practice Address - State: | MS |
| Practice Address - Zip Code: | 39212-2150 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 601-209-4278 |
| Practice Address - Fax: | |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2016-09-14 |
| Last Update Date: | 2016-09-14 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 311ZA0620X | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
| No | 310400000X | Nursing & Custodial Care Facilities | Assisted Living Facility | |
| No | 313M00000X | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | |
| No | 314000000X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | |
| No | 315P00000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Intellectual Disabilities | |
| No | 320600000X | Residential Treatment Facilities | Residential Treatment Facility, Intellectual and/or Developmental Disabilities | |
| No | 324500000X | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | |
| No | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | |
| No | 332BN1400X | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies |
| No | 332BX2000X | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
| No | 332U00000X | Suppliers | Home Delivered Meals | |
| No | 343800000X | Transportation Services | Secured Medical Transport (VAN) | |
| No | 347C00000X | Transportation Services | Private Vehicle | |
| No | 385H00000X | Respite Care Facility | Respite Care | |
| No | 385HR2060X | Respite Care Facility | Respite Care | Respite Care, Intellectual and/or Developmental Disabilities, Child |
