Provider Demographics
NPI:1679568455
Name:CEDAR KNOLL CARE CENTER
Entity Type:Organization
Organization Name:CEDAR KNOLL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:HUPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-522-8471
Mailing Address - Street 1:9230 CEDAR KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:GRASS LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49240-9633
Mailing Address - Country:US
Mailing Address - Phone:517-522-8471
Mailing Address - Fax:517-522-3066
Practice Address - Street 1:9230 CEDAR KNOLL DR
Practice Address - Street 2:
Practice Address - City:GRASS LAKE
Practice Address - State:MI
Practice Address - Zip Code:49240-9633
Practice Address - Country:US
Practice Address - Phone:517-522-8471
Practice Address - Fax:517-522-3066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3365195Medicaid
MI3365195Medicaid