Provider Demographics
NPI:1609916386
Name:CUMBERLAND MOUNTAIN COMMUNITY
Entity Type:Organization
Organization Name:CUMBERLAND MOUNTAIN COMMUNITY
Other - Org Name:BAXTER HOUSE ICF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MENTAL RETARDATION DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:F
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:276-964-6702
Mailing Address - Street 1:PO BOX 810
Mailing Address - Street 2:
Mailing Address - City:CEDAR BLUFF
Mailing Address - State:VA
Mailing Address - Zip Code:24609
Mailing Address - Country:US
Mailing Address - Phone:276-964-6702
Mailing Address - Fax:276-964-5669
Practice Address - Street 1:ROUTE 696
Practice Address - Street 2:
Practice Address - City:KEEN MOUNTAIN
Practice Address - State:VA
Practice Address - Zip Code:24624
Practice Address - Country:US
Practice Address - Phone:276-498-4549
Practice Address - Fax:276-498-4194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BAXTER HOUSE ICF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09301001315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004967810Medicaid