Provider Demographics
NPI:1790732337
Name:SUNBRIDGE HEALTHCARE LLC
Entity Type:Organization
Organization Name:SUNBRIDGE HEALTHCARE LLC
Other - Org Name:SUNNY RIDGE
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 1:2609 SUNNYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6332
Mailing Address - Country:US
Mailing Address - Phone:208-467-7298
Mailing Address - Fax:208-463-0901
Practice Address - Street 1:2609 SUNNYBROOK DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6332
Practice Address - Country:US
Practice Address - Phone:208-467-7298
Practice Address - Fax:208-463-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID46310400000X, 311Z00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8056570Medicaid
ID02188OtherBLUE CROSS OF IDAHO
ID0029216Medicaid
ID02188OtherTRUE BLUE
ID000010022479OtherBLUE SHIELD OF IDAHO
ID=========OtherAMERICAN REPUBLIC
ID0029216Medicaid
ID=========OtherAETNA
ID=========OtherBLUE CROSS/BLUE SHIELD OF
ID=========OtherPRINCIPAL FINANCIAL
ID02188OtherTRUE BLUE
ID=========OtherPIONEER LIFE
ID=========OtherUNITED HEALTHCARE
ID=========OtherPHYSICIANS MUTUAL
ID=========OtherAARP
ID=========OtherWASHINGTON NATIONAL
ID000010022479OtherBLUE SHIELD OF IDAHO
ID=========OtherTRICARE
ID=========OtherAMERICAN REPUBLIC