Provider Demographics
NPI:1295789295
Name:1300 CAMPBELL LANE OPERATING COMPANY LLC
Entity type:Organization
Organization Name:1300 CAMPBELL LANE OPERATING COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-591-5700
Mailing Address - Street 1:PO BOX 26657
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-6657
Mailing Address - Country:US
Mailing Address - Phone:559-892-2500
Mailing Address - Fax:559-892-2444
Practice Address - Street 1:1300 CAMPBELL LN
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4162
Practice Address - Country:US
Practice Address - Phone:270-782-6900
Practice Address - Fax:270-782-7228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY100655283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000273851OtherBLUE CROSS BLUE SHIELD
KY01000272Medicaid
KY01000272Medicaid
KY183029Medicare Oscar/Certification