Healthcare Provider Details

I. General information

NPI: 1497767321
Provider Name (Legal Business Name): VICTORY HOME HEALTH, PALLIATIVE, WAIVER SERVICES, INC,
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 HOT SPRINGS BLVD
LAS VEGAS NM
87701-4119
US

IV. Provider business mailing address

2810 HOT SPRINGS BLVD
LAS VEGAS NM
87701-4119
US

V. Phone/Fax

Practice location:
  • Phone: 505-454-0499
  • Fax: 505-425-9105
Mailing address:
  • Phone: 505-454-0499
  • Fax: 505-425-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number327113
License Number StateNM

VIII. Authorized Official

Name: MARIA LUISA PADILLA
Title or Position: EXECUTIVE DIRECTOR
Credential: RN
Phone: 505-454-0499