Provider Demographics
NPI:1528488996
Name:SUNNYSIDE COLLABORATIVE CARE
Entity type:Organization
Organization Name:SUNNYSIDE COLLABORATIVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SATYA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:ND, LAC
Authorized Official - Phone:503-658-7715
Mailing Address - Street 1:16144 SE HAPPY VALLEY TOWN CENTER DR
Mailing Address - Street 2:SUITE 214
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-4257
Mailing Address - Country:US
Mailing Address - Phone:503-658-7715
Mailing Address - Fax:503-658-7181
Practice Address - Street 1:16144 SE HAPPY VALLEY TOWN CENTER DR
Practice Address - Street 2:SUITE 214
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-4257
Practice Address - Country:US
Practice Address - Phone:503-658-7715
Practice Address - Fax:503-658-7181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR100484898261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service