=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710180955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORIAN SQUARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2007
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 241 S CHAMBERLAIN AVE
-----------------------------------------------------
City | ROCKWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37854-6542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-354-1133
-----------------------------------------------------
Fax | 865-354-6371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12933 W HIGHWAY 42
-----------------------------------------------------
City | PROSPECT
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40059-9107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-228-8131
-----------------------------------------------------
Fax | 502-228-1940
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | MR. RALPH H BELLANDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-228-8131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | ACL0000000147
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------