Basic Information
| Provider Information | |||||||||
| NPI: | 1417482852 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VINCENT VICTORIA VILLAGE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | HEALTHCORE SYSTEMS MANAGEMENT LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4607 E CALIFORNIA PKWY | ||||||||
| Address2: | |||||||||
| City: | FOREST HILL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761197571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172478259 | ||||||||
| FaxNumber: | 8175360177 | ||||||||
| Practice Location | |||||||||
| Address1: | 4607 E CALIFORNIA PKWY | ||||||||
| Address2: | |||||||||
| City: | FOREST HILL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761197571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172478259 | ||||||||
| FaxNumber: | 8175360177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2017 | ||||||||
| LastUpdateDate: | 04/24/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALVADOR | ||||||||
| AuthorizedOfficialFirstName: | RHODA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8172478259 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 143865 | TX | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.