Provider Demographics
NPI:1487470761
Name:BROCK LAMP LLC
Entity type:Organization
Organization Name:BROCK LAMP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WESBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-691-5059
Mailing Address - Street 1:64 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6017
Mailing Address - Country:US
Mailing Address - Phone:207-353-4318
Mailing Address - Fax:
Practice Address - Street 1:64 LISBON ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ME
Practice Address - Zip Code:04250-6017
Practice Address - Country:US
Practice Address - Phone:207-353-4318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility