Provider Demographics
NPI:1003853235
Name:SUNBRIDGE HEALTHCARE LLC
Entity Type:Organization
Organization Name:SUNBRIDGE HEALTHCARE LLC
Other - Org Name:BOISE BEHAVIORAL HEALTH HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:MATHIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-5013
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:8050 NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7126
Practice Address - Country:US
Practice Address - Phone:208-327-0504
Practice Address - Fax:208-327-0594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2013-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55283Q00000X
ID1650 HP (PHARM)283Q00000X
ID13D858805 (LAB)283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID2920900Medicaid
ID806765000Medicaid
ID806769400Medicaid
1257873Medicare ID - Type Unspecified
ID2920900Medicaid
ID806769400Medicaid