Provider Demographics
NPI:1487601704
Name:SUNBRIDGE STOCKTON REHABILITATION CENTER LLC
Entity type:Organization
Organization Name:SUNBRIDGE STOCKTON REHABILITATION CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-468-4752
Mailing Address - Street 1:9107 DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1807
Mailing Address - Country:US
Mailing Address - Phone:209-478-6488
Mailing Address - Fax:
Practice Address - Street 1:9107 DAVIS RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95209-1807
Practice Address - Country:US
Practice Address - Phone:209-478-6488
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REGENCY HEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-30
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100000358314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASNF55387FMedicaid
=========OtherNATIONWIDE
CASNF55387FMedicaid
=========OtherBLUE SHIELD OF CA
=========OtherHOSPICE OF SAN JOAQUIN
=========OtherMUTUAL OF OMAHA
=========OtherPENSIONED OPERATING ENGIN
=========OtherAETNA
=========OtherCOASTWISE
=========OtherASERA HOSPICE
=========OtherAARP
=========OtherUNITED HEALTHCARE
=========OtherAPWO HEALTH PLAN
=========OtherBANKER LIFE
=========OtherBANKER LIFE
CA555387Medicare Oscar/Certification