Provider Demographics
NPI:1285684068
Name:SUNBRIDGE GARDENDALE HEALTH CARE CENTER, LLC
Entity Type:Organization
Organization Name:SUNBRIDGE GARDENDALE HEALTH CARE CENTER, LLC
Other - Org Name:MAGNOLIA RIDGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICAHEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:420 DEAN DR
Mailing Address - Street 2:
Mailing Address - City:GARDENDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35071-2763
Mailing Address - Country:US
Mailing Address - Phone:205-631-8709
Mailing Address - Fax:205-608-1639
Practice Address - Street 1:420 DEAN DR
Practice Address - Street 2:
Practice Address - City:GARDENDALE
Practice Address - State:AL
Practice Address - Zip Code:35071-2763
Practice Address - Country:US
Practice Address - Phone:205-631-8709
Practice Address - Fax:205-608-1639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL16266314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL010-38OtherBCBS OF ALABAMA
AL4754730SMedicaid
=========OtherBANKER'S LIFE
=========OtherCIGNA
=========OtherNALC
=========OtherSTATE FARM
=========OtherUNITED HEALTHCARE
=========OtherHIGHMARK
=========OtherUMWA
=========OtherAETNA
=========OtherUNICARE
=========OtherVIVA
=========OtherUNICARE