Provider Demographics
NPI:1417093501
Name:SUNNYSIDE MANOR INC
Entity Type:Organization
Organization Name:SUNNYSIDE MANOR INC
Other - Org Name:SUNNYSIDE MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARYELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEANE
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:732-528-9311
Mailing Address - Street 1:2500 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9600
Mailing Address - Country:US
Mailing Address - Phone:732-528-9311
Mailing Address - Fax:732-528-9026
Practice Address - Street 1:2500 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9600
Practice Address - Country:US
Practice Address - Phone:732-528-9311
Practice Address - Fax:732-528-9026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061329314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9652OtherEMPIRE PROVIDER NUMBER
NJ7902506Medicaid
NJ7902506Medicaid