MEDICARE: VICTORY CENTRE OF SIERRA RIDGE 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
2	310400000X	Assisted Living Facility		IL

General Provider Information

NPI Number	:	1720275084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY CENTRE OF SIERRA RIDGE LLC

Provider Business Mailing Address
First Line	:	30 S WACKER DR STE 1010
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-7413
Country	:	US
Telephone Number	:	312-837-0701
Fax Number	:	312-837-0728

Provider Business Practice Location Address
First Line	:	4150 W. GATLING BOULEVARD
Second Line	:
City	:	COUNTRY CLUB HILLS
State	:	IL
Zip	:	60478-2024
Country	:	US
Telephone Number	:	708-957-8300
Fax Number	:	708-206-1499

Authorized Official
Title or Position	:	RISK MANAGER
Name	:	KRISTEN BECHT
Credential	:
Telephone Number	:	312-837-0710

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	04/11/2019

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