Provider Demographics
NPI:1689459745
Name:SD SUNNYSIDE LLC
Entity Type:Organization
Organization Name:SD SUNNYSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKESELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-397-4000
Mailing Address - Street 1:598 W 900 S STE 220
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84010-8195
Mailing Address - Country:US
Mailing Address - Phone:801-397-4697
Mailing Address - Fax:801-296-9117
Practice Address - Street 1:737 S 1300 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-3713
Practice Address - Country:US
Practice Address - Phone:801-582-5104
Practice Address - Fax:801-582-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility