Provider Demographics
NPI:1275744138
Name:SUMMERVILLE AT CLEARWATER LLC
Entity Type:Organization
Organization Name:SUMMERVILLE AT CLEARWATER LLC
Other - Org Name:BROOKDALE CLEARWATER
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:615-564-8131
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:925-866-8468
Practice Address - Street 1:2750 DREW STREET
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759
Practice Address - Country:US
Practice Address - Phone:727-799-2177
Practice Address - Fax:727-726-4145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL6670310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0110369-00Medicaid