Provider Demographics
NPI:1750338281
Name:SUNBRIDGE PUTNAM HEALTH CARE LLC
Entity type:Organization
Organization Name:SUNBRIDGE PUTNAM HEALTH CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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:505-821-3355
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 1:300 SEVILLE RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9206
Practice Address - Country:US
Practice Address - Phone:304-757-6805
Practice Address - Fax:304-757-3803
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE HEALTHCARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-30
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV91313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV#000324427OtherBCBS
WV0003982000Medicaid
TX=========OtherUMWA
GA=========OtherAARP
TX=========OtherAETNA FMC
PA=========OtherCIGNA
TN=========OtherSHEET METAL WORKERS
WV=========OtherACORDIA
FL=========OtherAMERICAN NETWORK
WV=========OtherTEAMSTERS
WV0003982000Medicaid
NY=========OtherAMALGAMETED
IL=========OtherBANKERS LIFE
NC=========OtherMUTUAL GROUP
GA=========OtherBANKERS FIDELITY
WA=========OtherCOMBINED INSURANCE
OH=========OtherSTATE FARM
TX=========OtherUNITED AMERICAN
TX=========OtherNATIONAL FINANCE