Basic Information
| Provider Information | |||||||||
| NPI: | 1932156460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUNBRIDGE GLENVILLE HEALTH CARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GLENVILLE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E STATE ST | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | KENNETT SQUARE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193483109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054684742 | ||||||||
| FaxNumber: | 5054688742 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 FAIRGROUND RD | ||||||||
| Address2: | |||||||||
| City: | GLENVILLE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263511388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3044625718 | ||||||||
| FaxNumber: | 3044628272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5054684752 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SUNBRIDGE CARE ENTERPRISES LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 94 | WV | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 94 | WV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | #001703821 | 01 | WV | BCBS | OTHER | 0004026000 | 05 | WV | MEDICAID |