Healthcare Provider Details

I. General information

NPI: 1396786919
Provider Name (Legal Business Name): SUNBRIDGE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 EAST LACANADA
AVONDALE AZ
85323-1643
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 623-932-2282
  • Fax: 623-925-8827
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberNCI378
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberNCI378
License Number StateAZ

VIII. Authorized Official

Name: MICHAEL BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-821-3355