Healthcare Provider Details

I. General information

NPI: 1063100949
Provider Name (Legal Business Name): VICTORIAN HOMES ADULT CARE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2023
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 S RURAL RD STE 104
TEMPE AZ
85282-3869
US

IV. Provider business mailing address

1204 E BASELINE RD STE 205
TEMPE AZ
85283-1453
US

V. Phone/Fax

Practice location:
  • Phone: 480-590-5644
  • Fax:
Mailing address:
  • Phone: 602-892-0633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CONSTANCE VICTORIA BOLTON
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-892-0633