1285687962 NPI number — SUNBRIDGE REGENCY - NORTH CAROLINA, LLC

Table of content: (NPI 1285687962)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285687962 NPI number — SUNBRIDGE REGENCY - NORTH CAROLINA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBRIDGE REGENCY - NORTH CAROLINA, 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:
ABBOTTS CREEK CENTER
Provider Other Organization Name Type Code:
3
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:
1285687962
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 E STATE ST
Provider Second Line Business Mailing Address:
COMPLIANCE DEPARTMENT
Provider Business Mailing Address City Name:
KENNETT SQUARE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19348-3109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-468-4742
Provider Business Mailing Address Fax Number:
505-468-8742

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
877 HILL EVERHART RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27295-9140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-248-6644
Provider Business Practice Location Address Fax Number:
336-224-0537
Provider Enumeration Date:
05/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIVITTORIO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO, TREASURER, ASST SECRETARY
Authorized Official Telephone Number:
610-444-6350

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0099 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: #17968 . This is a "PARTNERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 7803059 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0088K . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0088K . This is a "STATE BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3425333 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3426083 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345172 . This is a "MEDCOST/MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 71-08310 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".




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