1356471197 NPI number — MASONIC HOMES OF THE GRAND LODGE OF FREE & ACCEPTED MASONS

Table of content: (NPI 1356471197)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356471197 NPI number — MASONIC HOMES OF THE GRAND LODGE OF FREE & ACCEPTED MASONS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MASONIC HOMES OF THE GRAND LODGE OF FREE & ACCEPTED MASONS
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 ELIZABETHTOWN
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:
1356471197
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MASONIC 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:
17022-2199
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:
581 FREEMASON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIZABETHTOWN
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17022-3187
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-367-1121
Provider Business Practice Location Address Fax Number:
717-367-5813
Provider Enumeration Date:
03/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PRAZENICA
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
717-367-1121

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320900000X , with the licence number: 301790 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1000027230036 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1000027230026 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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