Provider Demographics
NPI:1144331216
Name:HBR CAMPBELL LANE, LLC
Entity type:Organization
Organization Name:HBR CAMPBELL LANE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-821-3355
Mailing Address - Street 1:101 SUN AVE NE
Mailing Address - Street 2:COMPLIANCE DEPARTMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4373
Mailing Address - Country:US
Mailing Address - Phone:505-468-5604
Mailing Address - Fax:505-468-4681
Practice Address - Street 1:1381 CAMPBELL LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1049
Practice Address - Country:US
Practice Address - Phone:270-843-0587
Practice Address - Fax:270-843-0874
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HBR KENTUCKY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100002190Medicaid
KY12503348Medicaid
KY12503348Medicaid