Provider Demographics
NPI:1083943898
Name:SUMMERVILLE AT OVIEDO, LLC
Entity Type:Organization
Organization Name:SUMMERVILLE AT OVIEDO, LLC
Other - Org Name:BROOKDALE OVIEDO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP, CHIEF ADMIN. OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:6155-654-8131
Mailing Address - Street 1:6737 W WASHINGTON ST STE 2300
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5650
Mailing Address - Country:US
Mailing Address - Phone:414-918-5000
Mailing Address - Fax:
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:2009-12-08
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X
FLAL9525310400000X
FLAL9825310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0089532-00Medicaid