Provider Demographics
NPI:1356486401
Name:LAKE CUMBERLAND DISTRICT HEALTH DEPT
Entity Type:Organization
Organization Name:LAKE CUMBERLAND DISTRICT HEALTH DEPT
Other - Org Name:WAYNE COUNTY HIGH 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 1:2 KENNY DAVIS BLVD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:KY
Practice Address - Zip Code:42633-9479
Practice Address - Country:US
Practice Address - Phone:606-378-5575
Practice Address - Fax:606-348-3458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
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
KY20001061Medicaid