Provider Demographics
NPI:1639438716
Name:BENEVOLENT CORPORATION CEDAR COMMUNITY
Entity Type:Organization
Organization Name:BENEVOLENT CORPORATION CEDAR COMMUNITY
Other - Org Name:CEDAR BAY ELKHART LAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-306-4212
Mailing Address - Street 1:5595 COUNTY ROAD Z
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-9224
Mailing Address - Country:US
Mailing Address - Phone:262-306-2100
Mailing Address - Fax:262-306-2126
Practice Address - Street 1:101 CEDAR LN
Practice Address - Street 2:
Practice Address - City:ELKHART LAKE
Practice Address - State:WI
Practice Address - Zip Code:53020-2142
Practice Address - Country:US
Practice Address - Phone:920-876-4050
Practice Address - Fax:920-876-4051
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BENEVOLENT CORPORATION CEDAR COMMUNITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-10
Last Update Date:2017-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0012455310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI0012455OtherCERTIFIED RESIDENTAL CARE FACILITY