Organization
VICTORIAN SQUARE, LLC
Active
Other names
Victorian Square Assisted Living Facility
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RALPH H BELLANDE (MANAGING PARTNER)
(502) 228-8131
Entity
Organization
Contact information
Practice address
241 S CHAMBERLAIN AVE, ROCKWOOD, TN 37854-6542
(865) 354-1133
(865) 354-6371
Mailing address
12933 W HIGHWAY 42, PROSPECT, KY 40059-9107
(502) 228-8131
(502) 228-1940
Taxonomy
Speciality
Code
Description
License number
State
3104A0625X
Assisted Living Facility (Mental Illness)
Primary
ACL0000000147
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4262690
TENNCARE/MEDICAID
TN
Enumeration date
06/06/2007
Last updated
01/24/2013
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