MEDICARE: VICTORY LAKE OPERATIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	00308961	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164419511
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY LAKE OPERATIONS, LLC

Provider Business Mailing Address
First Line	:	419 N QUAKER LN
Second Line	:
City	:	HYDE PARK
State	:	NY
Zip	:	12538-2933
Country	:	US
Telephone Number	:	845-229-9177
Fax Number	:	845-229-2734

Provider Business Practice Location Address
First Line	:	419 N QUAKER LN
Second Line	:
City	:	HYDE PARK
State	:	NY
Zip	:	12538-2933
Country	:	US
Telephone Number	:	845-229-9177
Fax Number	:	845-229-2734

Authorized Official
Title or Position	:	OPERATOR
Name	:	MR. GERALD J WOOD
Credential	:
Telephone Number	:	845-229-9177

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	01/15/2008

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Directions to “VICTORY LAKE OPERATIONS, LLC ” Practice Location

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