Basic Information
| Provider Information | |||||||||
| NPI: | 1659715027 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NIC 4 THE PLAZA LEASING LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE PLAZA AT PEMBROKE PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1700, NIC 4 THE PLAZA LEASING LLC | ||||||||
| Address2: | C/O HOLIDAY RETIREMENT | ||||||||
| City: | LAKE OSWEGO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712458020 | ||||||||
| FaxNumber: | 5034312295 | ||||||||
| Practice Location | |||||||||
| Address1: | 3535 SW 52ND AVE. | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549618111 | ||||||||
| FaxNumber: | 9549642871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2013 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | RYU | ||||||||
| AuthorizedOfficialFirstName: | JANE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 2124795270 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 5120 | FL | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 0047736 | 01 | FL | HOME & COMMUNITY BASED SERVICES | OTHER |