Healthcare Provider Details

I. General information

NPI: 1790232577
Provider Name (Legal Business Name): CEDAR LAKE LODGE/SYCAMORE RUN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9505 WILLIAMSBURG PLZ STE 200
LOUISVILLE KY
40222-5082
US

IV. Provider business mailing address

9505 WILLIAMSBURG PLZ STE 200
LOUISVILLE KY
40222-5082
US

V. Phone/Fax

Practice location:
  • Phone: 502-495-4953
  • Fax: 502-425-3540
Mailing address:
  • Phone: 502-495-4953
  • Fax: 502-425-3540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number101246
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number101247
License Number StateKY

VIII. Authorized Official

Name: MS. COURTNEY ELAINE GRIMES
Title or Position: REIMBURSEMENT SPECIALIST
Credential:
Phone: 502-495-4953