=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386637809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUGAR CREEK REST, LTD PTR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2005
-----------------------------------------------------
Last Update Date | 08/14/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 LAKESIDE DR
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16262-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-445-3146
-----------------------------------------------------
Fax | 724-445-3186
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 120 LAKESIDE DR
-----------------------------------------------------
City | WORTHINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16262-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-445-3146
-----------------------------------------------------
Fax | 724-445-3186
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | STEVEN D TACK
-----------------------------------------------------
Credential | NHA
-----------------------------------------------------
Telephone | 724-431-0770
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 195002
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------