Provider Demographics
NPI:1447396049
Name:CEDAR LAKE RESIDENCES, INC.
Entity Type:Organization
Organization Name:CEDAR LAKE RESIDENCES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM BILLING & REIMB SPVSR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-265-8389
Mailing Address - Street 1:9505 WILLIAMSBURG PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5082
Mailing Address - Country:US
Mailing Address - Phone:502-327-7706
Mailing Address - Fax:502-425-3540
Practice Address - Street 1:9505 WILLIAMSBURG PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5082
Practice Address - Country:US
Practice Address - Phone:502-327-7706
Practice Address - Fax:502-425-3540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100934251B00000X
251C00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled ServicesGroup - Single Specialty
No251B00000XAgenciesCase Management
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33900572Medicaid