=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649682865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT RETIREMENT LIFESTYLES C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2014
-----------------------------------------------------
Last Update Date | 05/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 HILLCREST HEIGHTS AVE
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-7970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-201-6999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 HILLCREST HEIGHTS AVE
-----------------------------------------------------
City | SAINT JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-7970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-201-6999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | FREDDIE MAYONTE ARGUILLA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-201-6999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | ALF # 12250
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------