Healthcare Provider Details

I. General information

NPI: 1598805012
Provider Name (Legal Business Name): LAKE CUMBERLAND AREA DEVELOPMENT DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2374 LAKEWAY DRIVE
RUSSELL SPRINGS KY
42642
US

IV. Provider business mailing address

PO BOX 1570
RUSSELL SPRINGS KY
42642-1570
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-4200
  • Fax: 270-866-4212
Mailing address:
  • Phone: 270-866-4200
  • Fax: 270-866-4212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateKY

VIII. Authorized Official

Name: DONNA DIAZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 270-866-4200