Provider Demographics
NPI:1619012812
Name:CEDARBROOK RESIDENTIAL CENTER, INC.
Entity Type:Organization
Organization Name:CEDARBROOK RESIDENTIAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:H
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LPC, NC LIC ADM
Authorized Official - Phone:828-652-4633
Mailing Address - Street 1:PO BOX 1257
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:NC
Mailing Address - Zip Code:28752-1257
Mailing Address - Country:US
Mailing Address - Phone:828-652-4633
Mailing Address - Fax:
Practice Address - Street 1:1267 PINNACLE CHURCH RD
Practice Address - Street 2:
Practice Address - City:NEBO
Practice Address - State:NC
Practice Address - Zip Code:28761-5753
Practice Address - Country:US
Practice Address - Phone:828-652-4633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL059021311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804606Medicaid