Basic Information
| Provider Information | |||||||||
| NPI: | 1508082728 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUNBRIDGE HARBOR VIEW REHABILITATION CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SUNBRIDGE HARBOR VIEW COMMUNITY SERVICES CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Practice Location | |||||||||
| Address1: | 850 E WARDLOW RD | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908074628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629819392 | ||||||||
| FaxNumber: | 5629812622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 12/28/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENCY HEALTH SERVICES LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | CA | N | Agencies | Case Management | 251S00000X | N | Agencies | Community/Behavioral Health | 251B00000X | 940000148 | CA | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 7270 | 05 | CA | MEDICAID |