Basic Information
| Provider Information | |||||||||
| NPI: | 1144331216 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HBR CAMPBELL LANE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAGNOLIA VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 SUN AVE NE | ||||||||
| Address2: | COMPLIANCE DEPARTMENT | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5054685604 | ||||||||
| FaxNumber: | 5054684681 | ||||||||
| Practice Location | |||||||||
| Address1: | 1381 CAMPBELL LN | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421041049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708430587 | ||||||||
| FaxNumber: | 2708430874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| AuthorizedOfficialLastName: | BERG | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 5058213355 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HBR KENTUCKY LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311500000X | KY | Y | Nursing & Custodial Care Facilities | Alzheimer Center (Dementia Center) |
ID Information
| ID | Type | State | Issuer | Description | 7100002190 | 05 | KY | MEDICAID | 12503348 | 05 | KY | MEDICAID |