Provider Demographics
NPI:1780639872
Name:HAMPTON HOUSE-WILKES-BARRE PA, LLC
Entity Type:Organization
Organization Name:HAMPTON HOUSE-WILKES-BARRE PA, LLC
Other - Org Name:HAMPTON HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-252-5743
Mailing Address - Street 1:333 N SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-2615
Mailing Address - Country:US
Mailing Address - Phone:419-252-5500
Mailing Address - Fax:877-385-9446
Practice Address - Street 1:1548 SANS SOUCI PKWY
Practice Address - Street 2:
Practice Address - City:HANOVER TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:18706-6028
Practice Address - Country:US
Practice Address - Phone:570-825-8725
Practice Address - Fax:570-825-4319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA080302314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020573730001Medicaid
PA1020573730001Medicaid