Provider Demographics
NPI:1689090292
Name:NIC 15 KIRKWOOD CORNERS LEASING LLC
Entity Type:Organization
Organization Name:NIC 15 KIRKWOOD CORNERS LEASING LLC
Other - Org Name:KIRKWOOD CORNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOETHEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-304-5033
Mailing Address - Street 1:2901 DALLAS PKWY
Mailing Address - Street 2:380
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5980
Mailing Address - Country:US
Mailing Address - Phone:469-304-5033
Mailing Address - Fax:
Practice Address - Street 1:206 N RIVER RD
Practice Address - Street 2:
Practice Address - City:LEE
Practice Address - State:NH
Practice Address - Zip Code:03861-6214
Practice Address - Country:US
Practice Address - Phone:603-659-6586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02985310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility