Provider Demographics
NPI:1093769408
Name:SUNBRIDGE CLIPPER HOME OF PORTSMOUTH LLC
Entity Type:Organization
Organization Name:SUNBRIDGE CLIPPER HOME OF PORTSMOUTH LLC
Other - Org Name:CLIPPER HARBOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4742
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 1:188 JONES AVE
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-5516
Practice Address - Country:US
Practice Address - Phone:603-431-2530
Practice Address - Fax:603-427-0507
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02453310400000X
NH02450311500000X, 313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
5BBOtherFEDERAL BC
NH99750159Medicaid
5BBOtherFEDERAL BC
=========OtherAARP
=========OtherCIGNA
=========OtherAETNA US HEALTHCARE
NH99750159Medicaid
=========OtherANTHEM BLUE CROSS
=========OtherSEACOAST HOSPICE
=========OtherHEALTH AMERICA
=========OtherAMERICAN
=========OtherBANKER'S LIFE & CASUALTY
=========OtherUNICARE