Healthcare Provider Details

I. General information

NPI: 1164045472
Provider Name (Legal Business Name): CEDAR HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 03/15/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 COUNTY ROAD 10
BROOKLYN CENTER MN
55429-3072
US

IV. Provider business mailing address

9300 30TH AVE N
MINNEAPOLIS MN
55427-2305
US

V. Phone/Fax

Practice location:
  • Phone: 651-706-2670
  • Fax:
Mailing address:
  • Phone: 651-706-2670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number StateNULL

VIII. Authorized Official

Name: VINCENT JEROME KING
Title or Position: OWNER
Credential:
Phone: 651-706-2670