Provider Demographics
NPI:1104876226
Name:SUNBRIDGE HEALTHCARE LLC
Entity type:Organization
Organization Name:SUNBRIDGE HEALTHCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:280 MT HEBRON RD
Mailing Address - Street 2:
Mailing Address - City:ELMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36025-1526
Mailing Address - Country:US
Mailing Address - Phone:334-567-8484
Mailing Address - Fax:
Practice Address - Street 1:280 MT HEBRON RD
Practice Address - Street 2:
Practice Address - City:ELMORE
Practice Address - State:AL
Practice Address - Zip Code:36025-1526
Practice Address - Country:US
Practice Address - Phone:334-567-8484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16967314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL010-693OtherBCBS OF ALABAMA, PO BOC 9
AL4750190SMedicaid
GA=========OtherAARP - POBOX 740819 ATLAN
AL4750190SMedicaid
KY=========OtherAETNA - PO BOX 14079 LEXI
ILTB=========OtherBCBS OF ILLINOIS - 300 EA
NE=========OtherPHYSICIANS MUTUAL - 2600
TX========= POLICY #OtherTRANSAMERICA LIFE INS - P
NE========= POLICY #0OtherPHYSICIANS MUTUAL INS - P