=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629287420
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMERVILLE AT GOLDEN POND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 06/13/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 450 67TH STREET NORTH
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-794-5657
-----------------------------------------------------
Fax | 941-798-3521
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6737 W WASHINGTON ST STE 2300
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53214-5650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-918-5000
-----------------------------------------------------
Fax | 206-301-4500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP, CHIEF ADMIN. OFFICER
-----------------------------------------------------
Name | BYRAN RICHARDSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 615-564-8131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL4712
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------