Basic Information
| Provider Information | |||||||||
| NPI: | 1699897215 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CEDARCREST, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 91 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033583384 | ||||||||
| FaxNumber: | 6033586485 | ||||||||
| Practice Location | |||||||||
| Address1: | 91 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034311629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033583384 | ||||||||
| FaxNumber: | 6033586485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | Q. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6033853384 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BA, BS, MBA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | 1709 | NH | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 80848084 | 05 | NH | MEDICAID | 030G001 | 05 | VT | MEDICAID |