MEDICARE: VICTORIOUS ASSITED LIVING HOME, 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	310400000X	Assisted Living Facility	AL10128H	AZ

General Provider Information

NPI Number	:	1538619358
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORIOUS ASSITED LIVING HOME, LLC

Provider Business Mailing Address
First Line	:	3501 W ORANGEWOOD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-6457
Country	:	US
Telephone Number	:	623-418-0512
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 W ORANGEWOOD AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85051-6457
Country	:	US
Telephone Number	:	623-418-0512
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. FLORA TERRONES
Credential	:
Telephone Number	:	623-418-0512

Provider Enumeration Date	:	10/04/2016
Last Update Date	:	10/04/2016

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