Provider Demographics
NPI:1699198812
Name:SUNNYSIDE OPERATIONS LLC
Entity type:Organization
Organization Name:SUNNYSIDE OPERATIONS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:KOFSTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:971-224-2033
Mailing Address - Street 1:25117 SW PARKWAY AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:503-570-3405
Mailing Address - Fax:503-570-3315
Practice Address - Street 1:4515 SUNNYSIDE RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3928
Practice Address - Country:US
Practice Address - Phone:503-370-8284
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR385189Medicare Oscar/Certification