=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396786919
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNBRIDGE HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2006
-----------------------------------------------------
Last Update Date | 07/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 EAST LACANADA
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-1643
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-932-2282
-----------------------------------------------------
Fax | 623-925-8827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 SUN AVE NE COMPLIANCE DEPARTMENT
-----------------------------------------------------
City | ALBUQUERQUE
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87109-4373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-468-5604
-----------------------------------------------------
Fax | 505-468-4681
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ASSISTANT SECRETARY
-----------------------------------------------------
Name | MICHAEL BERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-821-3355
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | NCI378
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | NCI378
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------