Healthcare Provider Details

I. General information

NPI: 1104126754
Provider Name (Legal Business Name): VICTORY PALACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2010
Last Update Date: 10/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 COLLEGE AVE NE
GRAND RAPIDS MI
49503-1751
US

IV. Provider business mailing address

908 COLLEGE AVE NE
GRAND RAPIDS MI
49503-1751
US

V. Phone/Fax

Practice location:
  • Phone: 616-214-8155
  • Fax: 616-214-8155
Mailing address:
  • Phone: 616-214-8155
  • Fax: 616-214-8155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAF410306794
License Number StateMI

VIII. Authorized Official

Name: MRS. IME ETUK
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 616-881-3843