MEDICARE: VICTAN OF NORTH CAROLINA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1083560981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTAN OF NORTH CAROLINA, LLC

Provider Business Mailing Address
First Line	:	525 N TRYON ST STE 1600
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-0213
Country	:	US
Telephone Number	:	904-672-8006
Fax Number	:

Provider Business Practice Location Address
First Line	:	2327 GREEN OAK DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-3922
Country	:	US
Telephone Number	:	904-672-8006
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	TANYA OLE
Credential	:
Telephone Number	:	904-672-8006

Provider Enumeration Date	:	03/05/2026
Last Update Date	:	03/05/2026

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