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

Table of Contents

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)





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