Basic Information
| Provider Information | |||||||||
| NPI: | 1851348460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBRIDGE NURSING HOME LLC | ||||||||
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| OtherOrganizationName: | EVERETT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTRMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 112TH ST SW | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982043784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4255131600 | ||||||||
| FaxNumber: | 4255131800 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2006 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | DIVITTORIO | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1164 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4111647 | 05 | WA | MEDICAID | EV6599 | 01 | WA | REGENCE | OTHER | 505491 | 01 | WA | STERLING | OTHER | 300856001 | 01 | WA | GROUP HEALTH | OTHER | 577 | 01 | WA | BLUE CROSS | OTHER |