Basic Information
| Provider Information | |||||||||
| NPI: | 1932199007 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBRIDGE CARE ENTERPRISES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKERSBURG CENTER | ||||||||
| 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: | 1716 GIHON RD | ||||||||
| Address2: | |||||||||
| City: | PARKERSBURG | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044855511 | ||||||||
| FaxNumber: | 3044853511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2005 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684742 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE HEALTHCARE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 71 | WV | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 71 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0004257000 | 05 | WV | MEDICAID |