MEDICARE: SUGAR HOUSE CARE AND REHAB, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	2008-NCF-114	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730328055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUGAR HOUSE CARE AND REHAB, INC

Provider Business Mailing Address
First Line	:	950 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2141
Country	:	US
Telephone Number	:	801-486-5121
Fax Number	:	801-486-5146

Provider Business Practice Location Address
First Line	:	950 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2141
Country	:	US
Telephone Number	:	801-486-5121
Fax Number	:	801-486-5146

Authorized Official
Title or Position	:	SYSTEMS ADMINISTRATOR
Name	:	MR. WILLIAM SCOTT THOMAS
Credential	:
Telephone Number	:	801-296-5106

Provider Enumeration Date	:	02/10/2009
Last Update Date	:	02/10/2009

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