Provider Demographics
NPI:1831126374
Name:SUNNYSIDE NURSING HOME
Entity Type:Organization
Organization Name:SUNNYSIDE NURSING HOME
Other - Org Name:SUNNYSIDE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:REED
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-766-4300
Mailing Address - Street 1:16561 US HIGHWAY 10
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56554-9302
Mailing Address - Country:US
Mailing Address - Phone:218-238-5944
Mailing Address - Fax:218-238-6854
Practice Address - Street 1:16561 US HIGHWAY 10
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:MN
Practice Address - Zip Code:56554-9302
Practice Address - Country:US
Practice Address - Phone:218-238-5944
Practice Address - Fax:218-238-6854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN00016314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND030315Medicaid
MN9513SUOtherBLUE CROSS BLUE SHIELD
MN710042OtherMEDICA
MN863840300Medicaid
MN863840300Medicaid