Healthcare Provider Details

I. General information

NPI: 1750338281
Provider Name (Legal Business Name): SUNBRIDGE PUTNAM 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

300 SEVILLE RD
HURRICANE WV
25526-9206
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 304-757-6805
  • Fax: 304-757-3803
Mailing address:
  • Phone: 505-468-5604
  • Fax: 505-468-4681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number91
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number91
License Number StateWV

VIII. Authorized Official

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