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General NPI Number Information
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NPI Number | 1316470081
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Entity Type | Organization
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Legal Business Name | VICTORY RESIDENTIAL HOME, LLC
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Dates
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Enumeration Date | 04/09/2017
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Last Update Date | 04/09/2017
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Provider Practice Location Address
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Address Line | 440 PLUMMER DR
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City | CHESAPEAKE
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State | VA
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Zip | 23323-3116
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Country | US
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Telephone | 757-673-4438
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Fax | 757-673-4438
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Provider Business Mailing Address
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Address Line | 440 PLUMMER DR
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City | CHESAPEAKE
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State | VA
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Zip | 23323-3116
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Country | US
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Telephone | 757-673-4438
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Fax | 757-673-4438
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Authorized Official
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Title or Position | CEO
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Name | MS. SONJA DENISE CARRAWAY
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Credential |
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Telephone | 757-567-3292
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 2648
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License Number State | VA
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