Provider Demographics
NPI:1932156460
Name:SUNBRIDGE GLENVILLE HEALTH CARE LLC
Entity Type:Organization
Organization Name:SUNBRIDGE GLENVILLE HEALTH CARE LLC
Other - Org Name:GLENVILLE 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 1:101 E STATE ST
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:KENNETT SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19348-3109
Mailing Address - Country:US
Mailing Address - Phone:505-468-4742
Mailing Address - Fax:505-468-8742
Practice Address - Street 1:111 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:GLENVILLE
Practice Address - State:WV
Practice Address - Zip Code:26351-1388
Practice Address - Country:US
Practice Address - Phone:304-462-5718
Practice Address - Fax:304-462-8272
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUNBRIDGE CARE ENTERPRISES 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
WV94313M00000X, 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#001703821OtherBCBS
WV0004026000Medicaid
UT=========OtherUNITED HEALTHCARE
CO=========OtherWV HEALTH ADMINISTRATION
KY=========OtherDOLDCMWC (BLACK LUNG)
WV=========OtherACORDIA NATIONAL
UT=========OtherUNITED HEALTHCARE OPTIONS
UT=========OtherUMWA
VA=========OtherNALC HEALTH BENEFITS
TX=========OtherUNITED AMERICAN INSURANCE
TX=========OtherUNITED HEALTHCARE
OH=========OtherMEDICAL MUTUAL OF OH
WV0004026000Medicaid
WV#001703821OtherBCBS
GA=========OtherAARP HEALTHCARE
WV=========OtherWV WORKERS COMP OFFICE OF