1811331283 NPI number — NIC 4 VILLAGE PLACE LEASING LLC

Table of content: (NPI 1811331283)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811331283 NPI number — NIC 4 VILLAGE PLACE LEASING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NIC 4 VILLAGE PLACE 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:
1811331283
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1700 C/O HOLIDAY RETIREMENT
Provider Second Line Business Mailing Address:
NIC 4 VILLAGE PLACE LEASING LLC
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:
18400 COCHRAN BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-766-8900
Provider Business Practice Location Address Fax Number:
941-766-8224
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:  9249 , 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: 009788900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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