Provider Demographics
NPI:1629025135
Name:SUNBRIDGE WEST TENNESSEE, LLC.
Entity Type:Organization
Organization Name:SUNBRIDGE WEST TENNESSEE, LLC.
Other - Org Name:TRENTON PLACE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT DIRECTOR
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:505-821-3355
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:2036 US HIGHWAY 45 BYP S
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-2941
Practice Address - Country:US
Practice Address - Phone:731-855-4500
Practice Address - Fax:731-855-2722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000090314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445308Medicaid
TN3004697OtherBLUE CROSS/BLUE SHIELD OF
TN7440445Medicaid
=========OtherAETNA INTERNATIONA
=========Other;LINCOLN HERITAGE
=========OtherSTATE FARM HEALTH
=========OtherHM BENEFITS ADMINISTRATOR
=========OtherANTHEM BENEFIT ADMINISTRA
=========OtherCHAMP VA
=========OtherAARP;
=========OtherCONTINENTAL GENERAL
=========OtherSTATE MUTUAL
=========OtherULLICO FAMILY OF COMPANIE
TN7440445Medicaid
=========OtherPIONEER LIFE
TN0445308Medicaid
=========OtherCONTINENTIAL LIFE
=========OtherNATIONAL FINANCIAL INS
=========OtherSTANDARD LIFE