MEDICARE: SD SUNNYSIDE LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1689459745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SD SUNNYSIDE LLC

Provider Business Mailing Address
First Line	:	598 W 900 S STE 220
Second Line	:
City	:	WOODS CROSS
State	:	UT
Zip	:	84010-8195
Country	:	US
Telephone Number	:	801-397-4697
Fax Number	:	801-296-9117

Provider Business Practice Location Address
First Line	:	737 S 1300 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3713
Country	:	US
Telephone Number	:	801-582-5104
Fax Number	:	801-582-8808

Authorized Official
Title or Position	:	BOARD PRESIDENT
Name	:	BRAD MIKESELL
Credential	:
Telephone Number	:	801-397-4000

Provider Enumeration Date	:	08/28/2023
Last Update Date	:	08/28/2023

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Directions to “SD SUNNYSIDE LLC ” Practice Location

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