Healthcare Provider Details

I. General information

NPI: 1376873257
Provider Name (Legal Business Name): SUMMERVILLE AT COBBCO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 05/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 PIEDMONT AVE
GLENDALE CA
91206-3448
US

IV. Provider business mailing address

6737 W WASHINGTON ST SUITE 2300
MILWAUKEE WI
53214-5647
US

V. Phone/Fax

Practice location:
  • Phone: 818-246-7457
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number197602411
License Number StateCA

VIII. Authorized Official

Name: BRYAN RICHARDSON
Title or Position: EVP, CHIEF ADMIN. OFFICER
Credential:
Phone: 615-564-8183