Healthcare Provider Details

I. General information

NPI: 1649224056
Provider Name (Legal Business Name): SUNBRIDGE REGENCY - NORTH CAROLINA, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 SMITH CHAPEL RD
MOUNT OLIVE NC
28365-1917
US

IV. Provider business mailing address

101 SUN AVE NE COMPLIANCE DEPARTMENT
ALBUQUERQUE NM
87109-4373
US

V. Phone/Fax

Practice location:
  • Phone: 919-658-9522
  • Fax: 919-658-5893
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNH0401
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0088K
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerBCBS
# 2
Identifier17968.
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerPARTNERS
# 3
Identifier0088K
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerSTATE BCBS
# 4
Identifier345126
Identifier TypeOTHER
Identifier State
Identifier IssuerMEDCOST/MULTIPLAN
# 5
Identifier3426287
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 6
Identifier3435126
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 7
Identifier71-08310
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerUNITED HEALTHCARE

VIII. Authorized Official

Name: MICHAEL T BERG
Title or Position: SECRETARY
Credential:
Phone: 610-444-6350