Provider Demographics
NPI:1194839704
Name:OUR SUMMER PLACE,LLC
Entity Type:Organization
Organization Name:OUR SUMMER PLACE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZATERA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-966-9978
Mailing Address - Street 1:PO BOX 3221
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23701-0221
Mailing Address - Country:US
Mailing Address - Phone:757-966-9978
Mailing Address - Fax:757-488-1008
Practice Address - Street 1:3511 BLAINE ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-3115
Practice Address - Country:US
Practice Address - Phone:757-483-4880
Practice Address - Fax:757-483-1578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA558305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service