Provider Demographics
NPI:1972593390
Name:INNOVATIVE HEALTH CARE PROPERTIES D B A SUMMER BROOK HEALTH CARE CENTE
Entity Type:Organization
Organization Name:INNOVATIVE HEALTH CARE PROPERTIES D B A SUMMER BROOK HEALTH CARE CENTE
Other - Org Name:INNOVATIVE HEALTH CARE PROPERTIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEWAYNE
Authorized Official - Middle Name:K
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-768-1506
Mailing Address - Street 1:5377 MONCRIEF RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-3159
Mailing Address - Country:US
Mailing Address - Phone:904-768-1506
Mailing Address - Fax:904-766-1772
Practice Address - Street 1:5377 MONCRIEF RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-3159
Practice Address - Country:US
Practice Address - Phone:904-768-1506
Practice Address - Fax:904-766-1772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSNF1132096314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLM52OtherHUMANA PROVIDER NUMBER
FL105138Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER