Basic Information
| Provider Information | |||||||||
| NPI: | 1396786919 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBRIDGE HEALTHCARE LLC | ||||||||
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| OtherOrganizationName: | ESTRELLA CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 EAST LACANADA | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853231643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239322282 | ||||||||
| FaxNumber: | 6239258827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 07/13/2015 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | NCI378 | AZ | N | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) | 314000000X | NCI378 | AZ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 340547 | 05 | AZ | MEDICAID | AHCCCS ID #:340547 | 01 | AZ | ARIZONA-MERCY CARE | OTHER | AHCCCS ID #:340547 | 01 | AZ | ARIZONA-LIFEMARK | OTHER |