Healthcare Provider Details

I. General information

NPI: 1932156460
Provider Name (Legal Business Name): SUNBRIDGE GLENVILLE HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 FAIRGROUND RD
GLENVILLE WV
26351-1388
US

IV. Provider business mailing address

101 E STATE ST COMPLIANCE DEPARTMENT
KENNETT SQUARE PA
19348-3109
US

V. Phone/Fax

Practice location:
  • Phone: 304-462-5718
  • Fax: 304-462-8272
Mailing address:
  • Phone: 505-468-4742
  • Fax: 505-468-8742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number94
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number94
License Number StateWV

VIII. Authorized Official

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