MEDICARE: VICTORIA HALL BLAKE

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	MHL-067-220	NC

General Provider Information

NPI Number	:	1801749551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA HALL BLAKE

Provider Business Mailing Address
First Line	:	412 SURRY CT
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-3955
Country	:	US
Telephone Number	:	910-340-1833
Fax Number	:

Provider Business Practice Location Address
First Line	:	412 SURRY CT
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-3955
Country	:	US
Telephone Number	:	910-340-1833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2026
Last Update Date	:	02/20/2026

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