1285078659 NPI number — NIC 4 SUNSET LAKE LEASING

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 1285078659 NPI number — NIC 4 SUNSET LAKE LEASING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIC 4 SUNSET LAKE LEASING
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:
1285078659
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:
C/O HOLIDAY RETIREMENT, PO BOX 1700
Provider Second Line Business Mailing Address:
NIC 4 SUNSET LAKE LEASING
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:
1121 JACARANDA BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VENICE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-497-1117
Provider Business Practice Location Address Fax Number:
941-492-3455
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:  9325 , 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: 003067300 . This is a "MEDICAID AGED/DISABLED ADULTS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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