Provider Demographics
NPI:1386124550
Name:VICTORIAN VILLA ASSISTED LIVING LLC
Entity type:Organization
Organization Name:VICTORIAN VILLA ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:517-315-1725
Mailing Address - Street 1:5585 BROOKLYN RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-8570
Mailing Address - Country:US
Mailing Address - Phone:517-764-4163
Mailing Address - Fax:
Practice Address - Street 1:5585 BROOKLYN RD SOUTH
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-8570
Practice Address - Country:US
Practice Address - Phone:517-764-4163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM380392463310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility