Healthcare Provider Details

I. General information

NPI: 1760229074
Provider Name (Legal Business Name): VICTORY GENTLECARE AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 07/12/2024
Certification Date: 07/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MELBOURNE RD
HURST TX
76053-6318
US

IV. Provider business mailing address

115 MELBOURNE RD
HURST TX
76053-6318
US

V. Phone/Fax

Practice location:
  • Phone: 682-227-2406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CELESTINA DURU
Title or Position: ADMINISTRATOR
Credential:
Phone: 469-766-1659