MEDICARE: SUMMERVILLE AT COBBCO, INC.

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	310400000X	Assisted Living Facility	374600735	CA

General Provider Information

NPI Number	:	1528397353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMMERVILLE AT COBBCO, INC.

Provider Business Mailing Address
First Line	:	3131 ELLIOTT AVE
Second Line	:	SUITE 500
City	:	SEATTLE
State	:	WA
Zip	:	98121-1044
Country	:	US
Telephone Number	:	206-298-2909
Fax Number	:	206-301-4500

Provider Business Practice Location Address
First Line	:	5219 CLAIREMONT MESA BLVD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-2206
Country	:	US
Telephone Number	:	858-292-8044
Fax Number	:	858-292-9644

Authorized Official
Title or Position	:	LICENSING SPECIALIST
Name	:	NOELLE DIAZ BICKEL
Credential	:
Telephone Number	:	206-298-2909

Provider Enumeration Date	:	12/07/2009
Last Update Date	:	12/07/2009

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