Provider Demographics
NPI:1033492145
Name:SUNNYBROOK SNF LLC
Entity Type:Organization
Organization Name:SUNNYBROOK SNF LLC
Other - Org Name:THE HERITAGE NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BUMPASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-399-6788
Mailing Address - Street 1:410 MONMOUTH AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1026 E GOODE ST
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:TX
Practice Address - Zip Code:75783-1641
Practice Address - Country:US
Practice Address - Phone:903-763-2284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-25
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX132408314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX675553Medicare Oscar/Certification