1194779504 NPI number — SUNBRIDGE RETIREMENT CARE ASSOCIATES LLC

Table of content: (NPI 1194779504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194779504 NPI number — SUNBRIDGE RETIREMENT CARE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBRIDGE RETIREMENT CARE ASSOCIATES 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:
PEMBROKE CARE AND REHABILITATION 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:
1194779504
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:
310 E WARDELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28372-7997
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-521-1273
Provider Business Practice Location Address Fax Number:
910-521-3593
Provider Enumeration Date:
05/20/2006

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:  NH0518 , 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: 0088K . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 341600N , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17968 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3415409 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345409 . 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".
  • Identifier: 0088K . This is a "STATE BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com