Provider Demographics
NPI:1407090434
Name:BRIGHTWATER RETIREMENT, LLC
Entity Type:Organization
Organization Name:BRIGHTWATER RETIREMENT, LLC
Other - Org Name:BRIGHTWATER
Other - Org Type:Other Name
Authorized Official - Title/Position:SR. VP OF ADMINISTRATION
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VENTOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-246-1610
Mailing Address - Street 1:101 BRIGHTWATER DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-8268
Mailing Address - Country:US
Mailing Address - Phone:843-903-8300
Mailing Address - Fax:843-236-1644
Practice Address - Street 1:101 BRIGHTWATER DR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-8268
Practice Address - Country:US
Practice Address - Phone:843-903-8300
Practice Address - Fax:843-236-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
SCCRC-1489310400000X
SCNCF-0955314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251E00000XAgenciesHome Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC425395Medicare Oscar/Certification