Healthcare Provider Details

I. General information

NPI: 1619842135
Provider Name (Legal Business Name): SUNNYSIDE AFH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4393 INDIGO ST NE
SALEM OR
97305-2137
US

IV. Provider business mailing address

4393 INDIGO ST NE
SALEM OR
97305-2137
US

V. Phone/Fax

Practice location:
  • Phone: 503-510-7236
  • Fax: 503-966-3990
Mailing address:
  • Phone: 503-510-7236
  • Fax: 503-966-3990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CHARLES MAINA KIMANI
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 503-510-7236