Provider Demographics
NPI:1700833977
Name:SUNBRIDGE CARE ENTERPRISES WEST LLC
Entity Type:Organization
Organization Name:SUNBRIDGE CARE ENTERPRISES WEST LLC
Other - Org Name:KINGSBURG 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:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:1101 STROUD AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:93631-1016
Mailing Address - Country:US
Mailing Address - Phone:559-897-5881
Mailing Address - Fax:
Practice Address - Street 1:1101 STROUD AVE
Practice Address - Street 2:
Practice Address - City:KINGSBURG
Practice Address - State:CA
Practice Address - Zip Code:93631-1016
Practice Address - Country:US
Practice Address - Phone:559-897-5881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENCY HEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-31
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA040000209314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZR05573HMedicaid
=========OtherMMA
=========OtherGE LIFE & ANNUITY
=========OtherSTANDARD LIFE
=========OtherBLUE CROSS LIFE & HEALTH
=========OtherNATIONWIDE HEALTH PLAN
=========OtherAARP
CAZZR05573HMedicaid