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General NPI Number Information
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NPI Number | 1780185181
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Entity Type | Organization
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Legal Business Name | LAKE CUMBERLAND VETERANS DIRECTED SERVICES
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Dates
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Enumeration Date | 02/22/2018
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Last Update Date | 02/22/2018
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Provider Practice Location Address
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Address Line | 2384 LAKEWAY DR
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City | RUSSELL SPRINGS
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State | KY
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Zip | 42642-4509
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Country | US
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Telephone | 270-866-4200
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1570
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City | RUSSELL SPRINGS
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State | KY
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Zip | 42642-1570
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Country | US
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Telephone | 270-866-4200
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DARRYL MCGAHA
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Credential |
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Telephone | 270-866-4200
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251X00000X
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Taxonomy Name | Supports Brokerage Agency
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License Number |
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License Number State |
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