1376897207 NPI number — MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA

Table of content: (NPI 1376897207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376897207 NPI number — MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
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:
MASONIC VILLAGE AT LAFAYETTE HILL
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:
1376897207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
581 FREEMASON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELIZABETHTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17022-3187
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-367-1121
Provider Business Mailing Address Fax Number:
717-367-5813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 RIDGE PIKE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE HILL
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19444-1744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-825-6100
Provider Business Practice Location Address Fax Number:
610-828-2803
Provider Enumeration Date:
10/30/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FORMICA
Authorized Official First Name:
PAMELA
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
717-367-1121

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  137102 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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