Provider Demographics
NPI:1639206493
Name:LAKE CUMBERLAND REG MHMR BOARD EPSDT
Entity Type:Organization
Organization Name:LAKE CUMBERLAND REG MHMR BOARD EPSDT
Other - Org Name:ADANTA GROUP EPSDT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HR DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-4782
Mailing Address - Street 1:130 SOUTHERN SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-3223
Mailing Address - Country:US
Mailing Address - Phone:606-679-4782
Mailing Address - Fax:606-678-5296
Practice Address - Street 1:130 SOUTHERN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-3223
Practice Address - Country:US
Practice Address - Phone:606-679-4782
Practice Address - Fax:606-678-5296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No251S00000XAgenciesCommunity/Behavioral Health