Provider Demographics
NPI:1871540385
Name:SUNBRIDGE REGENCY - TENNESSEE, LLC
Entity type:Organization
Organization Name:SUNBRIDGE REGENCY - TENNESSEE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:215 RICHARDSON WAY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807-3803
Practice Address - Country:US
Practice Address - Phone:865-992-5816
Practice Address - Fax:865-992-4031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000276314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN166895OtherBLUE CROSS BLUE SHIELD
TN7440459Medicaid
TN0445284Medicaid
TN166895OtherBLUE CROSS BLUE SHIELD
=========OtherNEW ERA LIFE
=========OtherAARP
=========OtherUNITED HEALTHCARE
=========OtherUNITED LETTER CARRIERS
=========OtherPIONEER LIFE
=========OtherBANKERS LIFE
TN0445284Medicaid
445284Medicare Oscar/Certification