Healthcare Provider Details

I. General information

NPI: 1992831713
Provider Name (Legal Business Name): LAKE CUMBERLAND REGIONAL MHMR BOARD OUTPATIENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 12/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 SOUTHERN SCHOOL RD
SOMERSET KY
42501-3223
US

IV. Provider business mailing address

130 SOUTHERN SCHOOL RD
SOMERSET KY
42501-3223
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-4782
  • Fax: 606-678-5296
Mailing address:
  • Phone: 606-679-4782
  • Fax: 606-678-5296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACK LEWIS
Title or Position: HR DIRECTOR
Credential:
Phone: 606-679-4782