Provider Demographics
NPI:1164711099
Name:SUGAR GROVE SENIOR LIVING, LLC
Entity Type:Organization
Organization Name:SUGAR GROVE SENIOR LIVING, LLC
Other - Org Name:SUGAR GROVE ASSISTED LIVING, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LACHELE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:HENKLE WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:HFA, MBA
Authorized Official - Phone:317-839-7900
Mailing Address - Street 1:5865 SUGAR LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-8322
Mailing Address - Country:US
Mailing Address - Phone:317-839-7900
Mailing Address - Fax:317-839-7985
Practice Address - Street 1:5865 SUGAR LN
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-8322
Practice Address - Country:US
Practice Address - Phone:317-839-7900
Practice Address - Fax:317-839-7985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-31
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11-012394-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201010030Medicaid