Provider Demographics
NPI:1154372969
Name:LITTLE BROOK HOME INC.
Entity type:Organization
Organization Name:LITTLE BROOK HOME INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:HAMPILOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:908-832-5265
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:CALIFON
Mailing Address - State:NJ
Mailing Address - Zip Code:07830-0398
Mailing Address - Country:US
Mailing Address - Phone:908-832-5265
Mailing Address - Fax:
Practice Address - Street 1:78 SLIKER RD
Practice Address - Street 2:
Practice Address - City:CALIFON
Practice Address - State:NJ
Practice Address - Zip Code:07830-4178
Practice Address - Country:US
Practice Address - Phone:908-832-2220
Practice Address - Fax:908-832-6626
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAZARE GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-15
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ061003314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8411204Medicaid
315467Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER