MEDICARE: SUNBRIDGE HEALTHCARE, LLC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	313M00000X	Nursing Facility/Intermediate Care Facility	02693	NH
2	310400000X	Assisted Living Facility	02693	NH
3	311500000X	Alzheimer Center (Dementia Center)	02693	NH
4	314000000X	Skilled Nursing Facility	02693	NH

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1619924479
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNBRIDGE HEALTHCARE, LLC

Provider Business Mailing Address
First Line	:	101 SUN AVE NE
Second Line	:	COMPLIANCE DEPARTMENT
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4373
Country	:	US
Telephone Number	:	505-468-5604
Fax Number	:	505-468-4681

Provider Business Practice Location Address
First Line	:	136A ARCH ST
Second Line	:
City	:	KEENE
State	:	NH
Zip	:	03431-2186
Country	:	US
Telephone Number	:	603-357-3902
Fax Number	:	603-358-4017

Authorized Official
Title or Position	:	PRESIDENT/DIRECTOR
Name	:	WILLIAM A. MATHIES
Credential	:
Telephone Number	:	505-468-5013

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	04/13/2011

136A ARCH ST
KEENE, NH
03431-2186

Practice Phone: 802-578-9171
Practice Fax:

136 ARCH ST
KEENE, NH
03431-2186