Basic Information
Provider Information | |||||||||
NPI: | 1457769119 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SUNNYSIDE COMMUNITY HOSPITAL HOME MEDICAL SUPPLY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 812 MILLER AVE | ||||||||
Address2: | STE G | ||||||||
City: | SUNNYSIDE | ||||||||
State: | WA | ||||||||
PostalCode: | 989442374 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098371700 | ||||||||
FaxNumber: | 5098360175 | ||||||||
Practice Location | |||||||||
Address1: | 812 MILLER AVE STE G | ||||||||
Address2: |   | ||||||||
City: | SUNNYSIDE | ||||||||
State: | WA | ||||||||
PostalCode: | 989442377 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5098371700 | ||||||||
FaxNumber: | 5098360175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2014 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GIBBONS | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5098371797 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.