Provider Demographics
NPI:1942282181
Name:SIGNATURE PROPERTIES OF SUTHERLAND LLC
Entity Type:Organization
Organization Name:SIGNATURE PROPERTIES OF SUTHERLAND LLC
Other - Org Name:SUTHERLAND CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHLHOP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-727-1768
Mailing Address - Street 1:8101 BIRCHWOOD CT
Mailing Address - Street 2:SUITE A, PO BOX 917
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-0917
Mailing Address - Country:US
Mailing Address - Phone:515-727-1770
Mailing Address - Fax:515-727-1771
Practice Address - Street 1:506 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SUTHERLAND
Practice Address - State:IA
Practice Address - Zip Code:51058
Practice Address - Country:US
Practice Address - Phone:712-446-3857
Practice Address - Fax:712-446-2633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA710198314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0805077Medicaid
IA0805077Medicaid