Healthcare Provider Details

I. General information

NPI: 1750545158
Provider Name (Legal Business Name): SUMMERVILLE AT PORT ORANGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2008
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 DUNLAWTON AVE
PORT ORANGE FL
32127-4755
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 386-761-1055
  • Fax: 386-761-4408
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL9792
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

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