Provider Demographics
NPI:1295095461
Name:VICKY'S LOVING HOME
Entity type:Organization
Organization Name:VICKY'S LOVING HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:Q
Authorized Official - Last Name:WHITEHAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-216-9638
Mailing Address - Street 1:3433 W MALAPAI DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-1240
Mailing Address - Country:US
Mailing Address - Phone:602-216-9638
Mailing Address - Fax:602-938-0156
Practice Address - Street 1:3433 W MALAPAI DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-1240
Practice Address - Country:US
Practice Address - Phone:602-216-9638
Practice Address - Fax:602-938-0156
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:V & E CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7043H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ347332Medicaid