Provider Demographics
NPI:1922218361
Name:SUMMERVILLE AT CARROLLWOOD, LLC
Entity Type:Organization
Organization Name:SUMMERVILLE AT CARROLLWOOD, LLC
Other - Org Name:BROOKDALE CAROLLWOOD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP, CHIEF ADMIN. OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BYRAN
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 1:13550 SOUTH VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618
Practice Address - Country:US
Practice Address - Phone:813-908-5300
Practice Address - Fax:813-908-5304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
310400000X, 311500000X
FLAL9134310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0111609-00Medicaid