1124075650 NPI number — SUNBRIDGE OF HARRIMAN LLC

Table of content: (NPI 1124075650)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124075650 NPI number — SUNBRIDGE OF HARRIMAN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBRIDGE OF HARRIMAN LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124075650
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 SUN AVE NE
Provider Second Line Business Mailing Address:
COMPLIANCE DEPARTMENT
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87109-4373
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-468-5604
Provider Business Mailing Address Fax Number:
505-468-4681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
257 PATTON LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARRIMAN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37748-8618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-354-3941
Provider Business Practice Location Address Fax Number:
865-354-9966
Provider Enumeration Date:
05/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATHIES
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT DIRECTOR
Authorized Official Telephone Number:
505-821-3355

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0000000212 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0093885 . This is a "BLUE CROSS/BLUE SHIELD OF" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 100044717 . This is a "PHP TENNCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1682240 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 445223 . This is a "CARITEN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0445223 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 445223 . This is a "CHAMP VA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7100143 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7440519 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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