Provider Demographics
NPI:1164559522
Name:DISTRICT 4 CDO PROGRAM
Entity Type:Organization
Organization Name:DISTRICT 4 CDO PROGRAM
Other - Org Name:BARREN RIVER AREA AGENCY ON AGING
Other - Org Type:Other Name
Authorized Official - Title/Position:ACTING EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-781-2381
Mailing Address - Street 1:PO BOX 90005
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-9005
Mailing Address - Country:US
Mailing Address - Phone:270-781-2381
Mailing Address - Fax:270-842-0768
Practice Address - Street 1:177 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-9175
Practice Address - Country:US
Practice Address - Phone:270-781-2381
Practice Address - Fax:270-842-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1700074600Medicaid