Cedar Lake Lodge, Inc.

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

License

100450 Issued in KY

Legal business name

CEDAR LAKE LODGE, INC.

Practice address

9505 Williamsburg PLZ Ste 200
Louisville, KY 40222-5089

Phone

(502) 265-8389

Fax

(502) 425-3540

NPI assigned

Jan 30, 2007

Last updated

Dec 21, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Courtney E Grimes, CPB

Title

Program Billing & Reimb Supervisor

Phone

(025) 265-8389

Specialties & licenses 6

Addresses

Other identifiers 3

Electronic endpoints 1

Tax ID family

Cedar Lake Lodge Inc2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Cedar Lake Lodge/Sycamore Run

  • Intellectual Disabilities Intermediate Care Facility
  • Louisville, KY
  • NPI 1790232577
  NPD tax ID

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• James E. Wheeler, M.D.

  • Family Medicine Physician
  • Louisville, KY
  • NPI 1275537094
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170115200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1608508800000",
    "number": "1568508190",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9505 WILLIAMSBURG PLZ STE 200",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402225089",
            "telephone_number": "502-265-8389",
            "fax_number": "502-425-3540"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9505 WILLIAMSBURG PLZ STE 200",
            "city": "LOUISVILLE",
            "state": "KY",
            "postal_code": "402225089",
            "telephone_number": "502-265-8389",
            "fax_number": "502-425-3540"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CEDAR LAKE LODGE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-30",
        "last_updated": "2020-12-21",
        "certification_date": "2020-12-21",
        "status": "A",
        "authorized_official_last_name": "GRIMES",
        "authorized_official_first_name": "COURTNEY",
        "authorized_official_middle_name": "E",
        "authorized_official_title_or_position": "PROGRAM BILLING & REIMB SUPERVISOR",
        "authorized_official_telephone_number": "025-265-8389",
        "authorized_official_credential": "CPB"
    },
    "taxonomies": [
        {
            "code": "310500000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Mental Illness",
            "state": "KY",
            "license": "101120",
            "primary": false
        },
        {
            "code": "313M00000X",
            "taxonomy_group": "",
            "desc": "Nursing Facility/Intermediate Care Facility",
            "state": "KY",
            "license": "101119",
            "primary": false
        },
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "KY",
            "license": "100450",
            "primary": true
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "385HR2060X",
            "taxonomy_group": "",
            "desc": "Respite Care, Respite Care, Intellectual and/or Developmental Disabilities, Child",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "11906153",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "43000512",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "33200353",
            "state": "KY"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "Louisville",
            "affiliation": "N",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "Louisville",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "Louisville",
            "address_1": "9505 Williamsburg Plz Ste 200",
            "city": "Louisville",
            "state": "KY",
            "country_code": "US",
            "postal_code": "402225089",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Mary Thompson Cecil, PT,CHT
• Michael H Cecil, PSYD, HSPP
• Michelle Cecil
• Nathanial Cecil, PHARMD
• Robert A Cecil Jr., P.T.
• Cedar Lake Lodge/Sycamore Run
• Cedar Lake Rehabilitation Services
• Cedar Lake Residences, Inc.
• Cedar Lake Residences, Inc.
• David Thomas Celello, D.M.D.

• Intellectual Disabilities Intermediate Care Facility in Louisville, KY
• Providers in Louisville, KY by specialty
• Intellectual Disabilities Intermediate Care Facility in Kentucky

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 21, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.