Provider Demographics
NPI:1902166556
Name:VICTORY ASSISTED LIVING HOME
Entity type:Organization
Organization Name:VICTORY ASSISTED LIVING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MACRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:NITIPRAWOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-301-4697
Mailing Address - Street 1:9321 APHRODITE DR
Mailing Address - Street 2:ANCHORAGE,ALASKA
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1493
Mailing Address - Country:US
Mailing Address - Phone:907-301-4697
Mailing Address - Fax:
Practice Address - Street 1:9321 APHRODITE DR
Practice Address - Street 2:ANCHORAGE,ALASKA
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1493
Practice Address - Country:US
Practice Address - Phone:907-301-4697
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3104A0625X, 3104A0630X
AK100911310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances