Provider Demographics
NPI:1285078659
Name:NIC 4 SUNSET LAKE LEASING
Entity type:Organization
Organization Name:NIC 4 SUNSET LAKE LEASING
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO/CFO
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RYU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-479-5270
Mailing Address - Street 1:C/O HOLIDAY RETIREMENT, PO BOX 1700
Mailing Address - Street 2:NIC 4 SUNSET LAKE LEASING
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035
Mailing Address - Country:US
Mailing Address - Phone:971-245-8020
Mailing Address - Fax:503-431-2295
Practice Address - Street 1:1121 JACARANDA BLVD.
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292
Practice Address - Country:US
Practice Address - Phone:941-497-1117
Practice Address - Fax:941-492-3455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9325310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003067300OtherMEDICAID AGED/DISABLED ADULTS