Provider Demographics
NPI:1780659136
Name:BROOK LANE HEALTH SERVICES
Entity Type:Organization
Organization Name:BROOK LANE HEALTH SERVICES
Other - Org Name:CHRONIC ONSITE
Other - Org Type:Other Name
Authorized Official - Title/Position:COORDINATOR/MANAGED CARE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:POFFENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-733-0331
Mailing Address - Street 1:13215 BROOK LANE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-1435
Mailing Address - Country:US
Mailing Address - Phone:301-733-0330
Mailing Address - Fax:301-733-4038
Practice Address - Street 1:13215 BROOK LANE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-1514
Practice Address - Country:US
Practice Address - Phone:301-733-0330
Practice Address - Fax:301-733-4038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2022-09-06
Deactivation Date:2018-05-31
Deactivation Code:
Reactivation Date:2022-09-06
Provider Licenses
StateLicense IDTaxonomies
MD21-002283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD986965400Medicaid
MD214003Medicare UPIN