Provider Demographics
NPI:1356914915
Name:GRAHAM, VICTORIUS VANDELLA
Entity type:Individual
Prefix:
First Name:VICTORIUS
Middle Name:VANDELLA
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1205
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-1205
Mailing Address - Country:US
Mailing Address - Phone:843-359-8280
Mailing Address - Fax:
Practice Address - Street 1:817 W VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-2226
Practice Address - Country:US
Practice Address - Phone:843-359-8280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-21
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC89-1774045Medicaid
SD861774045Medicaid