Provider Demographics
NPI:1477025609
Name:SUMMERS LANDING LLC
Entity Type:Organization
Organization Name:SUMMERS LANDING LLC
Other - Org Name:SUMMERS LANDING ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DELAMIELLEURE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:904-881-3773
Mailing Address - Street 1:615 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-1737
Mailing Address - Country:US
Mailing Address - Phone:904-881-3773
Mailing Address - Fax:
Practice Address - Street 1:615 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-1737
Practice Address - Country:US
Practice Address - Phone:904-881-3773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-28
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101318000Medicaid