Provider Demographics
NPI:1750331906
Name:SUNBRIDGE HEALTHCARE LLC
Entity Type:Organization
Organization Name:SUNBRIDGE HEALTHCARE LLC
Other - Org Name:KELLER LANDING
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 1:813 KELLER LN
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-1110
Mailing Address - Country:US
Mailing Address - Phone:256-383-1535
Mailing Address - Fax:256-383-2471
Practice Address - Street 1:813 KELLER LN
Practice Address - Street 2:
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674-1110
Practice Address - Country:US
Practice Address - Phone:256-383-1535
Practice Address - Fax:256-383-2471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17165314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
01046OtherFIRST COMMUNITY
TN3103139OtherBCBS
AL4005756OtherBCBS OF ALABAMA, PO BOC 9
AL4757710SMedicaid
AL4005756OtherBCBS OF ALABAMA, PO BOC 9
AL=========OtherUNITED HEALTHCARE OF ALA
01046OtherFIRST COMMUNITY
015028Medicare Oscar/Certification