Basic Information
| Provider Information | |||||||||
| NPI: | 1447619598 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAKE CUMBERLAND REG MHMR BOARD CDO | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE ADANTA GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 SOUTHERN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066794782 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 130 SOUTHERN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6066794782 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2016 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | HORTON | ||||||||
| AuthorizedOfficialFirstName: | TRACIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT TO THE CEO | ||||||||
| AuthorizedOfficialTelephone: | 6066794782 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 800019 | KY | Y | Agencies | Community/Behavioral Health |
No ID Information.