Provider Demographics
NPI:1174733653
Name:SUMMERVILLE SENIOR LIVING LLC
Entity type:Organization
Organization Name:SUMMERVILLE SENIOR LIVING LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF LICENSING
Authorized Official - Prefix:
Authorized Official - First Name:ANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA CERDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-866-1999
Mailing Address - Street 1:3000 EXECUTIVE PKWY
Mailing Address - Street 2:SUITE 530
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4255
Mailing Address - Country:US
Mailing Address - Phone:925-866-1999
Mailing Address - Fax:925-866-8468
Practice Address - Street 1:1725 PINE BARK POINT
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-977-5250
Practice Address - Fax:407-977-7122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9525310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)