Provider Demographics
NPI:1699710798
Name:CAMPBELL LODGE BOYS' HOME
Entity type:Organization
Organization Name:CAMPBELL LODGE BOYS' HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SCHROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:859-781-1214
Mailing Address - Street 1:5161 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:KY
Mailing Address - Zip Code:41076-3545
Mailing Address - Country:US
Mailing Address - Phone:859-781-1214
Mailing Address - Fax:859-442-3473
Practice Address - Street 1:5161 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-3545
Practice Address - Country:US
Practice Address - Phone:859-781-1214
Practice Address - Fax:859-442-3473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29100351Medicaid