Provider Demographics
NPI:1174574164
Name:SUNBRIDGE RETIREMENT CARE ASSOCIATES, LLC
Entity type:Organization
Organization Name:SUNBRIDGE RETIREMENT CARE ASSOCIATES, 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:610-444-6350
Mailing Address - Street 1:101 E STATE ST
Mailing Address - Street 2:REIMBURSEMENT DEPARTMENT
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:610-444-6350
Mailing Address - Fax:610-444-4395
Practice Address - Street 1:5131 WARM SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-4196
Practice Address - Country:US
Practice Address - Phone:706-561-1371
Practice Address - Fax:706-561-4055
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-13
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11061414314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00082684AMedicaid
115566Medicare Oscar/Certification