MEDICARE: SUMMERVILLE SENIOR LIVING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311500000X	Alzheimer Center (Dementia Center)	AL9525	FL
2	310400000X	Assisted Living Facility	AL9525	FL

General Provider Information

NPI Number	:	1174733653
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMERVILLE SENIOR LIVING LLC

Provider Business Mailing Address
First Line	:	3000 EXECUTIVE PKWY
Second Line	:	SUITE 530
City	:	SAN RAMON
State	:	CA
Zip	:	94583-4255
Country	:	US
Telephone Number	:	925-866-1999
Fax Number	:	925-866-8468

Provider Business Practice Location Address
First Line	:	1725 PINE BARK POINT
Second Line	:
City	:	OVIEDO
State	:	FL
Zip	:	32765
Country	:	US
Telephone Number	:	407-977-5250
Fax Number	:	407-977-7122

Authorized Official
Title or Position	:	DIRECTOR OF LICENSING
Name	:	ANA DE LA CERDA
Credential	:
Telephone Number	:	925-866-1999

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	09/11/2025

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