=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922016872
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VICTORIA HEALTHCARE PROPERTIES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2006
-----------------------------------------------------
Last Update Date | 01/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 MAIN
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-4957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-474-6885
-----------------------------------------------------
Fax | 479-474-9523
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 MAIN
-----------------------------------------------------
City | VAN BUREN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72956-4957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-474-6885
-----------------------------------------------------
Fax | 479-474-9523
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | JENNY JUNE KILGORE
-----------------------------------------------------
Credential | CPA
-----------------------------------------------------
Telephone | 479-474-6885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 728
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------