1003853235 NPI number — SUNBRIDGE HEALTHCARE LLC

Table of content: (NPI 1003853235)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003853235 NPI number — SUNBRIDGE HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBRIDGE HEALTHCARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BOISE BEHAVIORAL HEALTH HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003853235
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/22/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8050 NORTHVIEW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-7126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-327-0504
Provider Business Practice Location Address Fax Number:
208-327-0594
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATHIES
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
PRESIDENT DIRECTOR
Authorized Official Telephone Number:
505-468-5013

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , with the licence number:  55 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 1650 HP (PHARM) , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 283Q00000X , with the licence number: 13D858805 (LAB) , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2920900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806765000 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 806769400 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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