Provider Demographics
NPI:1851494124
Name:HOSPICE OF LAKE CUMBERLAND, INC.
Entity Type:Organization
Organization Name:HOSPICE OF LAKE CUMBERLAND, INC.
Other - Org Name:PALLIATIVE CARE OF LAKE CUMBERLAND
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-679-4389
Mailing Address - Street 1:100 PARKWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-679-4389
Mailing Address - Fax:606-679-2971
Practice Address - Street 1:100 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3450
Practice Address - Country:US
Practice Address - Phone:606-679-4389
Practice Address - Fax:606-679-2971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207QH0002X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251G00000XAgenciesHospice Care, Community BasedGroup - Multi-Specialty
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY44100014Medicaid
KY44100014Medicaid