Organization
CEDAR LAKE LODGE, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
COURTNEY E GRIMES CPB (PROGRAM BILLING & REIMB SUPERVISOR)
(025) 265-8389
Entity
Organization
Contact information
Practice address
9505 WILLIAMSBURG PLZ STE 200, LOUISVILLE, KY 40222-5089
(502) 265-8389
(502) 425-3540
Mailing address
9505 WILLIAMSBURG PLZ STE 200, LOUISVILLE, KY 40222-5089
(502) 265-8389
(502) 425-3540
Taxonomy
Speciality
Code
Description
License number
State
310500000X
Mental Illness Intermediate Care Facility
101120
KY
313M00000X
Nursing Facility/Intermediate Care Facility
101119
KY
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
100450
KY
315P00000X
Intellectual Disabilities Intermediate Care Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
385HR2060X
Child Intellectual and/or Developmental Disabilities Respite Care
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
11906153
—
KY
05
—
33200353
—
KY
05
—
43000512
—
KY
Enumeration date
01/30/2007
Last updated
12/21/2020
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