Basic Information
Provider Information | |||||||||
NPI: | 1922421437 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NIC 14 DAYTON LEASING LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAURELWOOD SENIOR LIVING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2901 DALLAS PKWY | ||||||||
Address2: | 380 | ||||||||
City: | PLANO | ||||||||
State: | TX | ||||||||
PostalCode: | 750935980 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4693045033 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3797 SUMMIT GLEN RD | ||||||||
Address2: |   | ||||||||
City: | DAYTON | ||||||||
State: | OH | ||||||||
PostalCode: | 454493661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9374122727 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/04/2014 | ||||||||
LastUpdateDate: | 03/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOETHEL | ||||||||
AuthorizedOfficialFirstName: | PAUL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE-PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4693045033 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 2032R | OH | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
No ID Information.