Provider Demographics
NPI:1598805012
Name:LAKE CUMBERLAND AREA DEVELOPMENT DISTRICT
Entity Type:Organization
Organization Name:LAKE CUMBERLAND AREA DEVELOPMENT DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-866-4200
Mailing Address - Street 1:PO BOX 1570
Mailing Address - Street 2:
Mailing Address - City:RUSSELL SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:42642-1570
Mailing Address - Country:US
Mailing Address - Phone:270-866-4200
Mailing Address - Fax:270-866-4212
Practice Address - Street 1:2374 LAKEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642
Practice Address - Country:US
Practice Address - Phone:270-866-4200
Practice Address - Fax:270-866-4212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3300148800Medicaid