Healthcare Provider Details

I. General information

NPI: 1568508190
Provider Name (Legal Business Name): CEDAR LAKE LODGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9505 WILLIAMSBURG PLZ STE 200
LOUISVILLE KY
40222-5089
US

IV. Provider business mailing address

9505 WILLIAMSBURG PLZ STE 200
LOUISVILLE KY
40222-5089
US

V. Phone/Fax

Practice location:
  • Phone: 502-265-8389
  • Fax: 502-425-3540
Mailing address:
  • Phone: 502-265-8389
  • Fax: 502-425-3540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number101120
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number101119
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number100450
License Number StateKY

VIII. Authorized Official

Name: COURTNEY E GRIMES
Title or Position: PROGRAM BILLING & REIMB SUPERVISOR
Credential: CPB
Phone: 25-265-8389