Provider Demographics
NPI:1093859258
Name:LAKE CUMBERLAND DISTRICT HEATLH DEPT
Entity Type:Organization
Organization Name:LAKE CUMBERLAND DISTRICT HEATLH DEPT
Other - Org Name:RUSSELL SPRINGS ELEMENTARY SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:D
Authorized Official - Last Name:CRABTREE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-678-4761
Mailing Address - Street 1:500 BOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-1916
Mailing Address - Country:US
Mailing Address - Phone:606-678-4761
Mailing Address - Fax:606-676-9671
Practice Address - Street 1:1554 N HIGHWAY 127
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-9502
Practice Address - Country:US
Practice Address - Phone:270-866-7850
Practice Address - Fax:270-866-7456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20104030Medicaid