1730489840 NPI number — LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC

Table of content: (NPI 1730489840)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730489840 NPI number — LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE CUMBERLAND PHYSICIAN PRACTICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PAIN CENTER OF LAKE CUMBERLAND
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730489840
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SEVEN SPRINGS WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-920-7000
Provider Business Mailing Address Fax Number:
615-920-8775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
305 LANGDON STREET
Provider Second Line Business Practice Location Address:
SUITE P
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-676-0206
Provider Business Practice Location Address Fax Number:
606-676-0220
Provider Enumeration Date:
10/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
SARA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
615-920-7514

Provider Taxonomy Codes

  • Taxonomy code: 208VP0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100143770 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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