Provider Demographics
NPI:1306841200
Name:CUMBERLAND VALLEY MANOR, INC.
Entity type:Organization
Organization Name:CUMBERLAND VALLEY MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-864-4315
Mailing Address - Street 1:PO BOX 438
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-0438
Mailing Address - Country:US
Mailing Address - Phone:270-864-4315
Mailing Address - Fax:270-864-3721
Practice Address - Street 1:301 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BURKESVILLE
Practice Address - State:KY
Practice Address - Zip Code:42717-9625
Practice Address - Country:US
Practice Address - Phone:270-864-4315
Practice Address - Fax:270-864-3721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-16
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100471314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY12501607Medicaid
KY12501607Medicaid
KY185270Medicare Oscar/Certification