Provider Demographics
NPI:1336172642
Name:LAKE CUMBERLAND REGIONAL MENTAL HEALTH MENTAL RETARDATION BOARD, INC.
Entity Type:Organization
Organization Name:LAKE CUMBERLAND REGIONAL MENTAL HEALTH MENTAL RETARDATION BOARD, INC.
Other - Org Name:THE ADANTA GROUP
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:2006-07-09
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY800019251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY5772Medicare PIN
KY5010Medicare PIN
KY0500907Medicare PIN
KY0264Medicare PIN
KY5007Medicare PIN
KY5129Medicare PIN
KY5009Medicare PIN
KY5011Medicare PIN
KY8677Medicare PIN
KY5003Medicare PIN
KY5008Medicare PIN
KY5012Medicare PIN
KY5002Medicare PIN
KY5004Medicare PIN
5005Medicare PIN
KY5001Medicare PIN
KY5006Medicare PIN