Provider Demographics
NPI:1649224056
Name:SUNBRIDGE REGENCY - NORTH CAROLINA, LLC.
Entity Type:Organization
Organization Name:SUNBRIDGE REGENCY - NORTH CAROLINA, LLC.
Other - Org Name:MOUNT OLIVE 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:610-444-6350
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 1:228 SMITH CHAPEL RD
Practice Address - Street 2:
Practice Address - City:MOUNT OLIVE
Practice Address - State:NC
Practice Address - Zip Code:28365-1917
Practice Address - Country:US
Practice Address - Phone:919-658-9522
Practice Address - Fax:919-658-5893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNH0401314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3426287Medicaid
345126OtherMEDCOST/MULTIPLAN
NC3435126Medicaid
NC71-08310OtherUNITED HEALTHCARE
NC0088KOtherSTATE BCBS
NC0088KOtherBCBS
NC17968.OtherPARTNERS
NC17968.OtherPARTNERS