Provider Demographics
NPI:1699001297
Name:SUGAR CREEK GROUP, LLC
Entity Type:Organization
Organization Name:SUGAR CREEK GROUP, LLC
Other - Org Name:SUGAR CREEK NURSING & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-557-1190
Mailing Address - Street 1:5430 W US HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-8803
Mailing Address - Country:US
Mailing Address - Phone:317-894-3301
Mailing Address - Fax:317-245-2510
Practice Address - Street 1:5430 W US HIGHWAY 40
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-8803
Practice Address - Country:US
Practice Address - Phone:317-894-3301
Practice Address - Fax:317-245-2510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09-00157-1314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100274720Medicaid
IN100274720Medicaid