1750331906 NPI number — SUNBRIDGE HEALTHCARE LLC

Table of content: (NPI 1750331906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750331906 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:
1750331906
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/30/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
813 KELLER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUSCUMBIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35674-1110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-383-1535
Provider Business Mailing Address Fax Number:
256-383-2471

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 KELLER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUSCUMBIA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35674-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-383-1535
Provider Business Practice Location Address Fax Number:
256-383-2471
Provider Enumeration Date:
05/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
ASSISTANT SECRETARY
Authorized Official Telephone Number:
505-468-4752

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  17165 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01046 . This is a "FIRST COMMUNITY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3103139 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4005756 . This is a "BCBS OF ALABAMA, PO BOC 9" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 4757710S , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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