Organization
CEDAR LAKE LODGE/SYCAMORE RUN
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. COURTNEY ELAINE GRIMES (REIMBURSEMENT SPECIALIST)
(502) 495-4953
Entity
Organization
Contact information
Practice address
9505 WILLIAMSBURG PLZ, STE 200, LOUISVILLE, KY 40222-5082
(502) 495-4953
(502) 425-3540
Mailing address
9505 WILLIAMSBURG PLZ, STE 200, LOUISVILLE, KY 40222-5082
(502) 495-4953
(502) 425-3540
Taxonomy
Speciality
Code
Description
License number
State
310500000X
Mental Illness Intermediate Care Facility
101246
KY
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
101247
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
101246
—
KY
05
—
101247
—
KY
Enumeration date
09/08/2016
Last updated
01/31/2022
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