Provider Demographics
NPI:1851348460
Name:SUNBRIDGE NURSING HOME LLC
Entity Type:Organization
Organization Name:SUNBRIDGE NURSING HOME LLC
Other - Org Name:EVERETT 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 DEPARTRMENT
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 1:1919 112TH ST SW
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-3784
Practice Address - Country:US
Practice Address - Phone:425-513-1600
Practice Address - Fax:425-513-1800
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1164314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4111647Medicaid
WAEV6599OtherREGENCE
WA505491OtherSTERLING
WA300856001OtherGROUP HEALTH
WA577OtherBLUE CROSS
WA=========OtherAMER HEALTH
WAEV6599OtherREGENCE
WA=========OtherAETNA
WA=========OtherODS
WA=========OtherREGENCE
WA=========OtherCARPENTER TRUST
WA=========OtherLIFE INVESTORS
WA=========OtherCONTINENTAL GENERAL
WA=========OtherSTANDARD LIFE
WA577OtherBLUE CROSS
WA=========OtherUNITED HEALTHCARE
WA=========OtherSTATE FARM
WA4111647Medicaid
WA=========OtherAARP