Provider Demographics
NPI:1871979575
Name:SUGARS SUPPORTIVE SERVICES, LLC
Entity type:Organization
Organization Name:SUGARS SUPPORTIVE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:ADELE
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-617-0400
Mailing Address - Street 1:2204 CITRUS BLVD
Mailing Address - Street 2:SUITE 10B
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3019
Mailing Address - Country:US
Mailing Address - Phone:352-435-4600
Mailing Address - Fax:352-435-4605
Practice Address - Street 1:2204 CITRUS BLVD
Practice Address - Street 2:SUITE 10B
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3019
Practice Address - Country:US
Practice Address - Phone:352-435-4600
Practice Address - Fax:352-435-4605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-04
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL001917900172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL690259696Medicaid
FL001917900Medicaid