Provider Demographics
NPI:1821414269
Name:SUNNYBROOK REHABILITATION CENTER, LLC
Entity Type:Organization
Organization Name:SUNNYBROOK REHABILITATION CENTER, LLC
Other - Org Name:SUNNYBROOK REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:R.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:CRONQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-574-2100
Mailing Address - Street 1:5887 GLENRIDGE DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5574
Mailing Address - Country:US
Mailing Address - Phone:404-574-2100
Mailing Address - Fax:404-574-2105
Practice Address - Street 1:25 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2782
Practice Address - Country:US
Practice Address - Phone:919-231-6150
Practice Address - Fax:919-231-8258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-10
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
NCNH0146314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821414269Medicaid
NC1821414269Medicaid