Healthcare Provider Details

I. General information

NPI: 1730418567
Provider Name (Legal Business Name): SUMMERVILLE 13, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 12/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15302 BROOKHURST ST
WESTMINSTER CA
92683-7099
US

IV. Provider business mailing address

3131 ELLIOTT AVE SUITE 500
SEATTLE WA
98121-1044
US

V. Phone/Fax

Practice location:
  • Phone: 714-775-6775
  • Fax: 714-839-1431
Mailing address:
  • Phone: 206-298-2909
  • Fax: 206-301-4500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number306002962
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number306002962
License Number StateCA

VIII. Authorized Official

Name: NOELLE DIAZ BICKEL
Title or Position: LICENSING SPECIALIST
Credential:
Phone: 206-298-2909