Healthcare Provider Details

I. General information

NPI: 1902166556
Provider Name (Legal Business Name): VICTORY ASSISTED LIVING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9321 APHRODITE DR ANCHORAGE,ALASKA
ANCHORAGE AK
99515-1493
US

IV. Provider business mailing address

9321 APHRODITE DR ANCHORAGE,ALASKA
ANCHORAGE AK
99515-1493
US

V. Phone/Fax

Practice location:
  • Phone: 907-301-4697
  • Fax:
Mailing address:
  • Phone: 907-301-4697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number100911
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: MACRISTINA NITIPRAWOTO
Title or Position: ADMINISTRATOR
Credential:
Phone: 907-301-4697