Healthcare Provider Details

I. General information

NPI: 1275744138
Provider Name (Legal Business Name): SUMMERVILLE AT CLEARWATER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 DREW STREET
CLEARWATER FL
33759
US

IV. Provider business mailing address

6737 W WASHINGTON ST STE 2300
MILWAUKEE WI
53214-5650
US

V. Phone/Fax

Practice location:
  • Phone: 727-799-2177
  • Fax: 727-726-4145
Mailing address:
  • Phone: 414-918-5000
  • Fax: 925-866-8468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL6670
License Number StateFL

VIII. Authorized Official

Name: BRYAN RICHARDSON
Title or Position: EVP, CHIEF ADMIN. OFFICER
Credential:
Phone: 615-564-8131