Provider Demographics
NPI:1780185181
Name:LAKE CUMBERLAND VETERANS DIRECTED SERVICES
Entity Type:Organization
Organization Name:LAKE CUMBERLAND VETERANS DIRECTED SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGAHA
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:
Practice Address - Street 1:2384 LAKEWAY DR
Practice Address - Street 2:
Practice Address - City:RUSSELL SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:42642-4509
Practice Address - Country:US
Practice Address - Phone:270-866-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage