Provider Demographics
NPI:1528203825
Name:LAKE CUMBERLAND DISTRICT HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:LAKE CUMBERLAND DISTRICT HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
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:
Practice Address - Street 1:500 BOURNE AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-1916
Practice Address - Country:US
Practice Address - Phone:606-678-4761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1639153034OtherNPI # OF DENTAL PROVIDER
KY6190128600Medicaid