MEDICARE: SUNBRIDGE PUTNAM HEALTH CARE 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	91	WV
2	314000000X	Skilled Nursing Facility	91	WV

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	#000324427	OTHER	WV	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1750338281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNBRIDGE PUTNAM 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	:	300 SEVILLE RD
Second Line	:
City	:	HURRICANE
State	:	WV
Zip	:	25526-9206
Country	:	US
Telephone Number	:	304-757-6805
Fax Number	:	304-757-3803

Authorized Official
Title or Position	:	ASSISTANT SECRETARY
Name	:	MICHAEL BERG
Credential	:
Telephone Number	:	505-821-3355

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

300 SEVILLE DR
HURRICANE, WV
25526-9206

Practice Phone: 323-928-9445
Practice Fax:

300 SEVILLE RD
HURRICANE, WV
25526-9206