Healthcare Provider Details

I. General information

NPI: 1831187079
Provider Name (Legal Business Name): BRADFORD ECUMENICAL HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SAINT FRANCIS DRIVE
BRADFORD PA
16701
US

IV. Provider business mailing address

100 SAINT FRANCIS DRIVE
BRADFORD PA
16701
US

V. Phone/Fax

Practice location:
  • Phone: 814-368-5648
  • Fax: 814-368-4642
Mailing address:
  • Phone: 814-368-5648
  • Fax: 814-368-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number281402
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0011692000001
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer
# 2
Identifier395908
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerMEDICARE

VIII. Authorized Official

Name: LISA A JOHNSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: CEO
Phone: 814-368-5648