Basic Information
| Provider Information | |||||||||
| NPI: | 1104034412 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMERVILLE AT PRINCE WILLIAM, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EMERITUS AT LAKE RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 3940 PRINCE WILLIAM PKWY | ||||||||
| Address2: | |||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036800600 | ||||||||
| FaxNumber: | 7036800790 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2007 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | DIAZ | ||||||||
| AuthorizedOfficialFirstName: | NOELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2062982909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | WLO-03-780 | VA | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 310400000X | WLO-03-780 | VA | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.