Healthcare Provider Details

I. General information

NPI: 1851348635
Provider Name (Legal Business Name): SUNBRIDGE HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1019 3RD AVE S
PAYETTE ID
83661-2832
US

IV. Provider business mailing address

1019 3RD AVE S
PAYETTE ID
83661-2832
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4455
  • Fax:
Mailing address:
  • Phone: 208-642-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number24
License Number StateID

VIII. Authorized Official

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