Provider Demographics
NPI:1568508190
Name:CEDAR LAKE LODGE, INC.
Entity Type:Organization
Organization Name:CEDAR LAKE LODGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM BILLING & REIMB SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:CPB
Authorized Official - Phone:025-265-8389
Mailing Address - Street 1:9505 WILLIAMSBURG PLZ STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5089
Mailing Address - Country:US
Mailing Address - Phone:502-265-8389
Mailing Address - Fax:502-425-3540
Practice Address - Street 1:9505 WILLIAMSBURG PLZ STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5089
Practice Address - Country:US
Practice Address - Phone:502-265-8389
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:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101120310500000X
KY101119313M00000X
KY100450315P00000X
315P00000X, 320900000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY43000512Medicaid
KY11906153Medicaid
KY33200353Medicaid