1659715027 NPI number — NIC 4 THE PLAZA LEASING LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659715027 NPI number — NIC 4 THE PLAZA LEASING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIC 4 THE PLAZA LEASING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659715027
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1700, NIC 4 THE PLAZA LEASING LLC
Provider Second Line Business Mailing Address:
C/O HOLIDAY RETIREMENT
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-245-8020
Provider Business Mailing Address Fax Number:
503-431-2295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3535 SW 52ND AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-961-8111
Provider Business Practice Location Address Fax Number:
954-964-2871
Provider Enumeration Date:
04/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RYU
Authorized Official First Name:
JANE
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO/CFO
Authorized Official Telephone Number:
212-479-5270

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  5120 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0047736 . This is a "HOME & COMMUNITY BASED SERVICES" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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