Basic Information
| Provider Information | |||||||||
| NPI: | 1033492145 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNNYBROOK SNF LLC | ||||||||
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| OtherOrganizationName: | THE HERITAGE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 MONMOUTH AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087013711 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1026 E GOODE ST | ||||||||
| Address2: | |||||||||
| City: | QUITMAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757831641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037632284 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2011 | ||||||||
| LastUpdateDate: | 12/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | BUMPASS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2543996788 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 132408 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.