Basic Information
| Provider Information | |||||||||
| NPI: | 1790011765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMERVILLE 2, LLC | ||||||||
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| OtherOrganizationName: | BRENTWOOD AT LAPORTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3131 ELLIOTT AVE | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981211044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062982909 | ||||||||
| FaxNumber: | 2063014500 | ||||||||
| Practice Location | |||||||||
| Address1: | 2002 ANDREW AVE | ||||||||
| Address2: | |||||||||
| City: | LA PORTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463506545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193251599 | ||||||||
| FaxNumber: | 2193621682 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2009 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | BICKEL | ||||||||
| AuthorizedOfficialFirstName: | NOELLE | ||||||||
| AuthorizedOfficialMiddleName: | DIAZ | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2062982909 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUMMERVILLE INVESTORS, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 07-010890-1 | IN | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.