Provider Demographics
NPI:1669214821
Name:SYCAMORE STREET, LLC
Entity type:Organization
Organization Name:SYCAMORE STREET, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLEGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-907-9818
Mailing Address - Street 1:13795 S MUR LEN RD STE 301
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1096
Mailing Address - Country:US
Mailing Address - Phone:919-907-9818
Mailing Address - Fax:
Practice Address - Street 1:5829 E 116TH ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9307
Practice Address - Country:US
Practice Address - Phone:317-807-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility