Provider Demographics
NPI:1376590976
Name:SUNBRIDGE CLIPPER HOME OF WOLFEBORO LLC
Entity Type:Organization
Organization Name:SUNBRIDGE CLIPPER HOME OF WOLFEBORO LLC
Other - Org Name:WOLFEBORO BAY CENTER
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 1:39 CLIPPER DR
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4222
Practice Address - Country:US
Practice Address - Phone:603-569-3950
Practice Address - Fax:603-569-6709
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-28
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02451310400000X, 311500000X, 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
850370802OtherGIC INDEMNITY
0000005BCOtherANTHEM BLUE CROSS
MN4J47SUOtherMN BC/BS
850370802OtherUNICARE INDEMNITY
NH99750169Medicaid
AL850370802OtherBC/BS
850370802OtherUNICARE INDEMNITY
850370802OtherGIC INDEMNITY
=========OtherAETNA
=========OtherBANKER'S LIFE & CASUALTY
=========OtherFEDERAL BC/BS
=========OtherAARP
NH99750169Medicaid
MN4J47SUOtherMN BC/BS