Healthcare Provider Details

I. General information

NPI: 1407090434
Provider Name (Legal Business Name): BRIGHTWATER RETIREMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BRIGHTWATER DR
MYRTLE BEACH SC
29579-8268
US

IV. Provider business mailing address

101 BRIGHTWATER DR
MYRTLE BEACH SC
29579-8268
US

V. Phone/Fax

Practice location:
  • Phone: 843-903-8300
  • Fax: 843-236-1644
Mailing address:
  • Phone: 843-903-8300
  • Fax: 843-236-1644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberCRC-1489
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCF-0955
License Number StateSC

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. GARY VENTOLA
Title or Position: SR. VP OF ADMINISTRATION
Credential:
Phone: 704-246-1610