Provider Demographics
NPI:1285687962
Name:SUNBRIDGE REGENCY - NORTH CAROLINA, LLC
Entity Type:Organization
Organization Name:SUNBRIDGE REGENCY - NORTH CAROLINA, LLC
Other - Org Name:ABBOTTS CREEK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO, TREASURER, ASST SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVITTORIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-444-6350
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:505-468-4742
Mailing Address - Fax:505-468-8742
Practice Address - Street 1:877 HILL EVERHART RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27295-9140
Practice Address - Country:US
Practice Address - Phone:336-248-6644
Practice Address - Fax:336-224-0537
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0099314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
#17968OtherPARTNERS
NC7803059Medicaid
0088KOtherBCBS
0088KOtherSTATE BCBS
NC3425333Medicaid
NC3426083Medicaid
345172OtherMEDCOST/MULTIPLAN
71-08310OtherUNITED HEALTHCARE
71-08310OtherUNITED HEALTHCARE