Healthcare Provider Details

I. General information

NPI: 1790732337
Provider Name (Legal Business Name): SUNBRIDGE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 SUNNYBROOK DR
NAMPA ID
83686-6332
US

IV. Provider business mailing address

2609 SUNNYBROOK DR
NAMPA ID
83686-6332
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-7298
  • Fax: 208-463-0901
Mailing address:
  • Phone: 208-467-7298
  • Fax: 208-463-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number46
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number46
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number46
License Number StateID

VIII. Authorized Official

Name: MICHAEL T. BERG
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 505-468-4752