Provider Demographics
NPI:1528402229
Name:NIC 4 BAYSIDE TERRACE LEASING LLC
Entity Type:Organization
Organization Name:NIC 4 BAYSIDE TERRACE LEASING LLC
Other - Org Name:BAYSIDE TERRACE
Other - Org Type:Doing Business As
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:PO BOX 1700, NIC 4 BAYSIDE TERRACE LEASING LLC
Mailing Address - Street 2:C/O HOLIDAY RETIREMENT
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:503-431-2296
Practice Address - Street 1:9381 U.S. 19
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33782
Practice Address - Country:US
Practice Address - Phone:727-576-1234
Practice Address - Fax:727-570-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6139310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004295900OtherMEDICAID AL WAIVER