Provider Demographics
NPI:1104126754
Name:VICTORY PALACE
Entity type:Organization
Organization Name:VICTORY PALACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IME
Authorized Official - Middle Name:
Authorized Official - Last Name:ETUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-881-3843
Mailing Address - Street 1:908 COLLEGE AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1751
Mailing Address - Country:US
Mailing Address - Phone:616-214-8155
Mailing Address - Fax:616-214-8155
Practice Address - Street 1:908 COLLEGE AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1751
Practice Address - Country:US
Practice Address - Phone:616-214-8155
Practice Address - Fax:616-214-8155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410306794311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home