Healthcare Provider Details

I. General information

NPI: 1730489840
Provider Name (Legal Business Name): LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 09/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 LANGDON STREET SUITE P
SOMERSET KY
42503
US

IV. Provider business mailing address

330 SEVEN SPRINGS WAY
BRENTWOOD TN
37027
US

V. Phone/Fax

Practice location:
  • Phone: 606-676-0206
  • Fax: 606-676-0220
Mailing address:
  • Phone: 615-920-7000
  • Fax: 615-920-8775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: SARA MILLER
Title or Position: DIRECTOR
Credential:
Phone: 615-920-7514