Healthcare Provider Details

I. General information

NPI: 1619810462
Provider Name (Legal Business Name): VICTORY MANOR GROUP HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2026
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 ABERDEEN DR
DAVENPORT FL
33896-8397
US

IV. Provider business mailing address

396 ABERDEEN DR
DAVENPORT FL
33896-8397
US

V. Phone/Fax

Practice location:
  • Phone: 863-313-3122
  • Fax:
Mailing address:
  • Phone: 863-313-3122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. CANDI SEVERSON
Title or Position: OWNER
Credential:
Phone: 863-313-3122