Provider Demographics
NPI:1730391947
Name:SUNNYBROOK ASSISTED LIVING, INC.
Entity type:Organization
Organization Name:SUNNYBROOK ASSISTED LIVING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:HOWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:641-469-5778
Mailing Address - Street 1:3000 W MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:IA
Mailing Address - Zip Code:52556-4205
Mailing Address - Country:US
Mailing Address - Phone:641-469-5778
Mailing Address - Fax:641-469-4529
Practice Address - Street 1:3000 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:IA
Practice Address - Zip Code:52556-4205
Practice Address - Country:US
Practice Address - Phone:641-469-5778
Practice Address - Fax:641-469-4529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IASO170310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0158717Medicaid