1295789295 NPI number — 1300 CAMPBELL LANE OPERATING COMPANY LLC

Table of content: (NPI 1295789295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295789295 NPI number — 1300 CAMPBELL LANE OPERATING COMPANY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1300 CAMPBELL LANE OPERATING COMPANY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHERN KENTUCKY REHABILITATION HOSPITAL
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295789295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26657
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93729-6657
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-892-2500
Provider Business Mailing Address Fax Number:
559-892-2444

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1300 CAMPBELL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOWLING GREEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42104-4162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-782-6900
Provider Business Practice Location Address Fax Number:
270-782-7228
Provider Enumeration Date:
05/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLINGER
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
717-591-5700

Provider Taxonomy Codes

  • Taxonomy code: 283X00000X , with the licence number:  100655 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000273851 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 01000272 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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