Provider Demographics
NPI:1083295588
Name:LAKE CUMBERLAND RECOVERY, INC
Entity Type:Organization
Organization Name:LAKE CUMBERLAND RECOVERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKKLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-516-9939
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:BURNSIDE
Mailing Address - State:KY
Mailing Address - Zip Code:42519-0305
Mailing Address - Country:US
Mailing Address - Phone:606-618-9966
Mailing Address - Fax:606-341-1218
Practice Address - Street 1:81 W HIGHWAY 80 STE B
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2700
Practice Address - Country:US
Practice Address - Phone:606-618-9966
Practice Address - Fax:606-341-1218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE CUMBERLAND RECOVERY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-16
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder