Provider Demographics
NPI:1851354039
Name:CEDAR LAKE NURSING SERVICES, INC
Entity Type:Organization
Organization Name:CEDAR LAKE NURSING SERVICES, INC
Other - Org Name:CEDAR LAKE HOME HEALTH AND HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:903-489-2043
Mailing Address - Street 1:104 S TERRY ST
Mailing Address - Street 2:
Mailing Address - City:MALAKOFF
Mailing Address - State:TX
Mailing Address - Zip Code:75148-9206
Mailing Address - Country:US
Mailing Address - Phone:903-489-2043
Mailing Address - Fax:903-489-2044
Practice Address - Street 1:104 S TERRY ST
Practice Address - Street 2:
Practice Address - City:MALAKOFF
Practice Address - State:TX
Practice Address - Zip Code:75148-9206
Practice Address - Country:US
Practice Address - Phone:903-489-2043
Practice Address - Fax:903-489-2044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1440251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00205800Medicaid
TX023676201Medicaid
TX303932OtherUNITED HEALTHCARE
TX00205800Medicaid
TX303932OtherUNITED HEALTHCARE