1649224056 NPI number — SUNBRIDGE REGENCY - NORTH CAROLINA, LLC.

Table of content: (NPI 1649224056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649224056 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:
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:
1649224056
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2015
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:
228 SMITH CHAPEL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT OLIVE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28365-1917
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-658-9522
Provider Business Practice Location Address Fax Number:
919-658-5893
Provider Enumeration Date:
05/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIVITTORIO
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT DIRECTOR
Authorized Official Telephone Number:
610-444-6350

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0401 , 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: 3426287 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345126 . This is a "MEDCOST/MULTIPLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3435126 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 71-08310 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0088K . This is a "STATE BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0088K . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 17968. . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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