Provider Demographics
NPI:1386637809
Name:SUGAR CREEK REST, LTD PTR
Entity Type:Organization
Organization Name:SUGAR CREEK REST, LTD PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:724-431-0770
Mailing Address - Street 1:120 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:16262-5102
Mailing Address - Country:US
Mailing Address - Phone:724-445-3146
Mailing Address - Fax:724-445-3186
Practice Address - Street 1:120 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:PA
Practice Address - Zip Code:16262-5102
Practice Address - Country:US
Practice Address - Phone:724-445-3146
Practice Address - Fax:724-445-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-30
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA195002313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000966807001Medicaid
PA1039012OtherGATEWAY HP
PA111736OtherUNISON
0613OtherHIGHMARK BC
PA263510OtherHEALTH AMERICA
209144OtherUPMC
MA0240400001OtherNHIC,CORP
395410Medicare ID - Type Unspecified