1053367367 NPI number — SUNBRIDGE HEALTHCARE LLC

Table of content: KATHARINE LEIGH JURGENSEN FNP (NPI 1366842809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053367367 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:
Provider Other Organization Name Type Code:
6
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:
1053367367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2013
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:
640 FILER AVE W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TWIN FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83301-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-734-8645
Provider Business Practice Location Address Fax Number:
208-734-4645
Provider Enumeration Date:
05/26/2006

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:
505-821-3355

Provider Taxonomy Codes

  • Taxonomy code: 311500000X , with the licence number:  32 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 32 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8750370802 . This is a "AMERICAN PIONEER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "APWU HEALTH PLAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "CIGNA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "DMBA/SE IDAHO EMP COALITI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "FARMER STOCKMAN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 01305 . This is a "BLUE CROSS OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "BLUE CROSS /BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "EQUITABLE LIFE & CASUALTY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000010013057 . This is a "BLUE SHIELD OF IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "AARP GROUP HEALTH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "BC/BS OF MN" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "CHAMPUS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "AETNA LIFE INS CO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "BC/BS OF UTAH" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "FEDERAL HOME LIFE INS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 0029215 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8750370802 . This is a "BANKERS LIFE & CASUALTY" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "BC/BS OF MI" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 8750370802 . This is a "DESERET MUTUAL BENEFITS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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