Healthcare Provider Details

I. General information

NPI: 1689018301
Provider Name (Legal Business Name): NIC 4 THE GRANDE LEASING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 12/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 DESOTO AVENUE
BROOKSVILLE FL
34601
US

IV. Provider business mailing address

PO BOX 1700 C/O HOLIDAY RETIREMENT NIC 4 THE GRANDE LEASING LLC
LAKE OSWEGO OR
97035
US

V. Phone/Fax

Practice location:
  • Phone: 352-544-0944
  • Fax:
Mailing address:
  • Phone: 971-245-8020
  • Fax: 503-431-2295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number11732
License Number StateFL

VIII. Authorized Official

Name: JANE RYU
Title or Position: PRESIDENT/CEO/CFO
Credential:
Phone: 212-479-5270