Provider Demographics
NPI:1790232577
Name:CEDAR LAKE LODGE/SYCAMORE RUN
Entity Type:Organization
Organization Name:CEDAR LAKE LODGE/SYCAMORE RUN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REIMBURSEMENT SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-495-4953
Mailing Address - Street 1:9505 WILLIAMSBURG PLZ
Mailing Address - Street 2:STE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5082
Mailing Address - Country:US
Mailing Address - Phone:502-495-4953
Mailing Address - Fax:502-425-3540
Practice Address - Street 1:9505 WILLIAMSBURG PLZ
Practice Address - Street 2:STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5082
Practice Address - Country:US
Practice Address - Phone:502-495-4953
Practice Address - Fax:502-425-3540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-08
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY101246310500000X
KY101247315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY101246Medicaid
KY101247Medicaid