Provider Demographics
NPI:1790165561
Name:CEDAR LAKE REHABILITATION SERVICES
Entity Type:Organization
Organization Name:CEDAR LAKE REHABILITATION SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCIAL SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:KERSTING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-327-7706
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CEDAR LAKE RESIDENCES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-05
Last Update Date:2015-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100934261QH0700X, 261QP2000X, 261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33900572Medicaid