1336196963 NPI number — SUNBRIDGE GOODWIN NURSING HOME LLC

Table of content: (NPI 1336196963)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336196963 NPI number — SUNBRIDGE GOODWIN NURSING HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNBRIDGE GOODWIN NURSING HOME 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:
EXETER ON HAMPTON CARE AND REHABILITATION CENTER
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:
1336196963
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
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:
8 HAMPTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EXETER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03833-4806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-778-0531
Provider Business Practice Location Address Fax Number:
603-778-0797
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
505-468-4742

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  02448 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 02448 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 99750132 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CT BC/BS . This is a "CT BC/BS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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