Basic Information
| Provider Information | |||||||||
| NPI: | 1124075650 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBRIDGE OF HARRIMAN LLC | ||||||||
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| OtherOrganizationName: | RENAISSANCE TERRACE CARE AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 257 PATTON LN | ||||||||
| Address2: | |||||||||
| City: | HARRIMAN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377488618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653543941 | ||||||||
| FaxNumber: | 8653549966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2006 | ||||||||
| LastUpdateDate: | 09/29/2009 | ||||||||
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| AuthorizedOfficialLastName: | MATHIES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000212 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0093885 | 01 | TN | BLUE CROSS/BLUE SHIELD OF | OTHER | 100044717 | 01 | PHP TENNCARE | OTHER | 1682240 | 01 | CIGNA | OTHER | 445223 | 01 | CARITEN | OTHER | 0445223 | 05 | TN | MEDICAID | 445223 | 01 | CHAMP VA | OTHER | 7100143 | 01 | UNITED HEALTHCARE | OTHER | 7440519 | 05 | TN | MEDICAID |