Healthcare Provider Details

I. General information

NPI: 1619012812
Provider Name (Legal Business Name): CEDARBROOK RESIDENTIAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1267 PINNACLE CHURCH RD
NEBO NC
28761-5753
US

IV. Provider business mailing address

PO BOX 1257
MARION NC
28752-1257
US

V. Phone/Fax

Practice location:
  • Phone: 828-652-4633
  • Fax:
Mailing address:
  • Phone: 828-652-4633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberHAL059021
License Number StateNC

VIII. Authorized Official

Name: MR. FRED H LEONARD
Title or Position: PRESIDENT
Credential: MS, LPC, NC LIC. ADM
Phone: 828-652-4633