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General NPI Number Information
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NPI Number | 1619810462
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Entity Type | Organization
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Legal Business Name | VICTORY MANOR GROUP HOME LLC
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Dates
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Enumeration Date | 04/14/2026
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Last Update Date | 04/14/2026
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Provider Practice Location Address
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Address Line | 396 ABERDEEN DR
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City | DAVENPORT
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State | FL
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Zip | 33896-8397
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Country | US
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Telephone | 863-313-3122
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Fax |
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Provider Business Mailing Address
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Address Line | 396 ABERDEEN DR
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City | DAVENPORT
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State | FL
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Zip | 33896-8397
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Country | US
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Telephone | 863-313-3122
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. CANDI SEVERSON
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Credential |
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Telephone | 863-313-3122
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State |
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