Healthcare Provider Details

I. General information

NPI: 1831489459
Provider Name (Legal Business Name): VICTORY MULTICARE NURSING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2011
Last Update Date: 03/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 HUNTCLIFF TRCE
DOUGLASVILLE GA
30135-8428
US

IV. Provider business mailing address

4350 HUNTCLIFF TRCE
DOUGLASVILLE GA
30135-8428
US

V. Phone/Fax

Practice location:
  • Phone: 770-942-8033
  • Fax: 770-942-8033
Mailing address:
  • Phone: 770-942-8033
  • Fax: 770-942-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number048-R-0836
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number048-R-0836
License Number StateGA

VIII. Authorized Official

Name: MS. CLARA OKPOMO
Title or Position: CEO
Credential: RN,BSN
Phone: 770-942-8033