1770755902 NPI number — CEDAR LAKE NURSING SERVICES, INC

Table of content: (NPI 1770755902)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770755902 NPI number — CEDAR LAKE NURSING SERVICES, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR LAKE NURSING SERVICES, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770755902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 2025
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MALAKOFF
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-489-2023
Provider Business Mailing Address Fax Number:
903-489-2044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
218 PARK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRINIDAD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75163-6060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-489-2044
Provider Business Practice Location Address Fax Number:
903-489-2044
Provider Enumeration Date:
03/27/2008

Additional Information

Authorized Official

Authorized Official Last Name:
NORWOOD
Authorized Official First Name:
MARY
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD MEMBER
Authorized Official Telephone Number:
903-292-7467

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  1440 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HH6837 . This is a "BLUE CROSS AND BLUE SHIEL" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 000205800 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: HH6962 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH6996 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: HH6838 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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