Basic Information
Provider Information | |||||||||
NPI: | 1811331283 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NIC 4 VILLAGE PLACE LEASING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VILLAGE PLACE RETIREMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1700 C/O HOLIDAY RETIREMENT | ||||||||
Address2: | NIC 4 VILLAGE PLACE LEASING LLC | ||||||||
City: | LAKE OSWEGO | ||||||||
State: | OR | ||||||||
PostalCode: | 97035 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9712458020 | ||||||||
FaxNumber: | 5034312295 | ||||||||
Practice Location | |||||||||
Address1: | 18400 COCHRAN BLVD. | ||||||||
Address2: |   | ||||||||
City: | PORT CHARLOTTE | ||||||||
State: | FL | ||||||||
PostalCode: | 33948 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9417668900 | ||||||||
FaxNumber: | 9417668224 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2013 | ||||||||
LastUpdateDate: | 11/22/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RYU | ||||||||
AuthorizedOfficialFirstName: | JANE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO/CFO | ||||||||
AuthorizedOfficialTelephone: | 2124795270 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 9249 | FL | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.