Provider Demographics
NPI:1699348466
Name:SUNNYSIDE HOME HEALTHCARE LLC
Entity type:Organization
Organization Name:SUNNYSIDE HOME HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-262-2081
Mailing Address - Street 1:2065 WALTON RD STE 111
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-5805
Mailing Address - Country:US
Mailing Address - Phone:314-262-2081
Mailing Address - Fax:
Practice Address - Street 1:3431 BRIDGELAND DR STE H
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2648
Practice Address - Country:US
Practice Address - Phone:314-262-2081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-20
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health