Basic Information
| Provider Information | |||||||||
| NPI: | 1285684068 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNBRIDGE GARDENDALE HEALTH CARE CENTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAGNOLIA RIDGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 DEAN DR | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056318709 | ||||||||
| FaxNumber: | 2056081639 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 DEAN DR | ||||||||
| Address2: | |||||||||
| City: | GARDENDALE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350712763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2056318709 | ||||||||
| FaxNumber: | 2056081639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 03/30/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICAHEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 16266 | AL | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 010-38 | 01 | AL | BCBS OF ALABAMA | OTHER | 4754730S | 05 | AL | MEDICAID |