Provider Demographics
NPI:1902132749
Name:SUMMERVILLE AT ST. AUGUSTINE, LLC
Entity type:Organization
Organization Name:SUMMERVILLE AT ST. AUGUSTINE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNOZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-918-5443
Mailing Address - Street 1:150 MARINER HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-3215
Mailing Address - Country:US
Mailing Address - Phone:904-794-9988
Mailing Address - Fax:
Practice Address - Street 1:150 MARINER HEALTH WAY
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3215
Practice Address - Country:US
Practice Address - Phone:904-794-9988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-29
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9908310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0124330-00Medicaid