MEDICARE: SUNNYSIDE NURSING HOME

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	00016	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	9513SU	OTHER	MN	BLUE CROSS BLUE SHIELD
3	710042	OTHER	MN	MEDICA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831126374
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNNYSIDE NURSING HOME

Provider Business Mailing Address
First Line	:	16561 US HIGHWAY 10
Second Line	:
City	:	LAKE PARK
State	:	MN
Zip	:	56554-9302
Country	:	US
Telephone Number	:	218-238-5944
Fax Number	:	218-238-6854

Provider Business Practice Location Address
First Line	:	16561 US HIGHWAY 10
Second Line	:
City	:	LAKE PARK
State	:	MN
Zip	:	56554-9302
Country	:	US
Telephone Number	:	218-238-5944
Fax Number	:	218-238-6854

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	SCOTT REED RIDDLE
Credential	:
Telephone Number	:	615-766-4300

Provider Enumeration Date	:	06/28/2006
Last Update Date	:	09/12/2012

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Directions to “SUNNYSIDE NURSING HOME ” Practice Location

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