MEDICARE: SUNBRIDGE SALEM HEALTH CARE LLC

Medicare Provider Information

Scope of Practice

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	95	WV
2	314000000X	Skilled Nursing Facility	95	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	000324428	OTHER	WV	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1669429197
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNBRIDGE SALEM HEALTH CARE 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	:	255 SUNBRIDGE DR
Second Line	:
City	:	SALEM
State	:	WV
Zip	:	26426-8400
Country	:	US
Telephone Number	:	304-782-3000
Fax Number	:	304-782-3003

Authorized Official
Title or Position	:	ASSISTANT SECRETARY
Name	:	MICHAEL T. BERG
Credential	:
Telephone Number	:	505-468-4752

Provider Enumeration Date	:	05/30/2006
Last Update Date	:	08/17/2018

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