MEDICARE: INNOVATIVE HEALTH CARE PROPERTIES D B A SUMMER BROOK HEALTH CARE CENTE

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	314000000X	Skilled Nursing Facility	SNF1132096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M52	OTHER	FL	HUMANA PROVIDER NUMBER

General Provider Information

NPI Number	:	1972593390
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE HEALTH CARE PROPERTIES D B A SUMMER BROOK HEALTH CARE CENTE

Provider Business Mailing Address
First Line	:	5377 MONCRIEF RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3159
Country	:	US
Telephone Number	:	904-768-1506
Fax Number	:	904-766-1772

Provider Business Practice Location Address
First Line	:	5377 MONCRIEF RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32209-3159
Country	:	US
Telephone Number	:	904-768-1506
Fax Number	:	904-766-1772

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. DEWAYNE K HARVEY
Credential	:
Telephone Number	:	904-768-1506

Provider Enumeration Date	:	10/26/2005
Last Update Date	:	08/22/2020

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