Provider Demographics
NPI:1659573004
Name:SUMMERVILLE AT HERITAGE PLACE, LLC
Entity Type:Organization
Organization Name:SUMMERVILLE AT HERITAGE PLACE, LLC
Other - Org Name:EMERITUS AT HERITAGE PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LICENSING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NOELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-301-4060
Mailing Address - Street 1:3000 EXECUTIVE PKWY
Mailing Address - Street 2:SUITE 530
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4255
Mailing Address - Country:US
Mailing Address - Phone:925-866-1999
Mailing Address - Fax:925-866-8468
Practice Address - Street 1:355 W GRANT LINE RD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-2500
Practice Address - Country:US
Practice Address - Phone:209-835-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397003261310400000X, 311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)