Basic Information
| Provider Information | |||||||||
| NPI: | 1619924479 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBRIDGE HEALTHCARE, LLC | ||||||||
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| OtherOrganizationName: | LANGDON PLACE OF KEENE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 136A ARCH ST | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034312186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033573902 | ||||||||
| FaxNumber: | 6033584017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 04/13/2011 | ||||||||
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| AuthorizedOfficialLastName: | MATHIES | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5054685013 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 02693 | NH | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 310400000X | 02693 | NH | N | Nursing & Custodial Care Facilities | Assisted Living Facility | 311500000X | 02693 | NH | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 314000000X | 02693 | NH | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 30100462 | 05 | NH | MEDICAID |