1891792354 NPI number — LUTHERAN HOME FOR THE AGED

Table of content: (NPI 1891792354)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891792354 NPI number — LUTHERAN HOME FOR THE AGED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUTHERAN HOME FOR THE AGED
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:
THE VILLAGE AT LUTHER SQUARE
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:
1891792354
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
149 W 22ND ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERIE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16502-2804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
814-452-3271
Provider Business Mailing Address Fax Number:
814-456-0383

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149 W 22ND ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERIE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16502-2804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
814-452-3271
Provider Business Practice Location Address Fax Number:
814-456-0383
Provider Enumeration Date:
06/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
GUSEK
Authorized Official First Name:
MARK
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
C EO
Authorized Official Telephone Number:
814-452-3271

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  382602 , 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)

  • Identifier: 0648 . This is a "BLUE CROSS PROVIDER NO." identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1007767250002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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