MEDICARE: VICTORY MANOR GROUP HOME 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	320800000X	Mental Illness Community Based Residential Treatment Facility
2	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1619810462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICTORY MANOR GROUP HOME LLC

Provider Business Mailing Address
First Line	:	396 ABERDEEN DR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33896-8397
Country	:	US
Telephone Number	:	863-313-3122
Fax Number	:

Provider Business Practice Location Address
First Line	:	396 ABERDEEN DR
Second Line	:
City	:	DAVENPORT
State	:	FL
Zip	:	33896-8397
Country	:	US
Telephone Number	:	863-313-3122
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. CANDI SEVERSON
Credential	:
Telephone Number	:	863-313-3122

Provider Enumeration Date	:	04/14/2026
Last Update Date	:	04/14/2026

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