Healthcare Provider Details

I. General information

NPI: 1972315414
Provider Name (Legal Business Name): VICTORY HOME CARE AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2025
Last Update Date: 10/21/2025
Certification Date: 10/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 E MICHIGAN BLVD
MICHIGAN CITY IN
46360-5372
US

IV. Provider business mailing address

2302 E MICHIGAN BLVD
MICHIGAN CITY IN
46360-5372
US

V. Phone/Fax

Practice location:
  • Phone: 574-334-3290
  • Fax:
Mailing address:
  • Phone: 219-229-4421
  • Fax: 219-200-2919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: KHALILAH ODOM
Title or Position: MANAGER
Credential:
Phone: 219-229-4421