Provider Demographics
NPI:1710321112
Name:NIC 4 SOUTHERN GARDENS LEASING LLC
Entity Type:Organization
Organization Name:NIC 4 SOUTHERN GARDENS LEASING LLC
Other - Org Name:SOUTHERN GARDENS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIGMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-479-5343
Mailing Address - Street 1:255 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-2133
Mailing Address - Country:US
Mailing Address - Phone:212-479-5343
Mailing Address - Fax:
Practice Address - Street 1:255 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE ALFRED
Practice Address - State:FL
Practice Address - Zip Code:33850-2133
Practice Address - Country:US
Practice Address - Phone:212-479-5343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-29
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8937310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689986200OtherMEDICAID AL WAIVER
FL1423860OtherMEDICAID ACS