Provider Demographics
NPI:1760438063
Name:SUNBRIDGE HEALTHCARE LLC
Entity Type:Organization
Organization Name:SUNBRIDGE HEALTHCARE LLC
Other - Org Name:CHERRY RIDGE 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 1:501 W IDAHO BLVD
Mailing Address - Street 2:
Mailing Address - City:EMMETT
Mailing Address - State:ID
Mailing Address - Zip Code:83617-9694
Mailing Address - Country:US
Mailing Address - Phone:208-365-3597
Mailing Address - Fax:208-365-5107
Practice Address - Street 1:501 W IDAHO BLVD
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9694
Practice Address - Country:US
Practice Address - Phone:208-365-3597
Practice Address - Fax:208-365-5107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID34314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010012586OtherBLUE SHIELD OF IDAHO
ID01867OtherBLUE CROSS OF IDAHO
ID0029214Medicaid
ID=========OtherBANKERS LIFE & CASUALTY
ID=========OtherAMER INCOME LIFE INS
ID=========OtherBOISE MEMORIAL HOSPICE
ID=========OtherCENTRAL STATES HEALTH OF
ID=========OtherBLUE CROSS FEDERAL
ID=========OtherEQUITABLE LIFE & CASUALTY
ID=========OtherAPWU HEALTH PLAN
ID000010012586OtherBLUE SHIELD OF IDAHO
ID=========OtherBLUE CROSS OF OREGON
ID=========OtherAARP
ID=========OtherBLUE CROSS IBM EMPIRE
ID=========OtherITT INDUSTRIES
ID01867OtherBLUE CROSS OF IDAHO
ID=========OtherAMER PIONEER LIFE
ID=========OtherBLUE CROSS OF CA
ID=========OtherGEHA/US GOVERNMENT
ID=========OtherGEHA/US GOVERNMENT