Basic Information
| Provider Information | |||||||||
| NPI: | 1861643595 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BROOK LANE HEALTH SERVICES/STONEBRIDGE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13121 BROOK LANE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Practice Location | |||||||||
| Address1: | 13218 BROOK LANE DRIVE | ||||||||
| Address2: | |||||||||
| City: | HAGERSTOWN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217421945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017330330 | ||||||||
| FaxNumber: | 3017334038 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 11/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | POFFENBERGER | ||||||||
| AuthorizedOfficialFirstName: | KRISTY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGED CARE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 3017330331 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BROOK LANE HEALTH SERVICES/STONEBRIDGE | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 00075 | MD | Y | Hospitals | Psychiatric Hospital |
No ID Information.