Healthcare Provider Details

I. General information

NPI: 1720332653
Provider Name (Legal Business Name): MASONIC VILLAGES OF THE GRAND LODGE OF PENNSYLVANIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 FREEMASON DR
ELIZABETHTOWN PA
17022-3187
US

IV. Provider business mailing address

1 MASONIC DR
ELIZABETHTOWN PA
17022-2199
US

V. Phone/Fax

Practice location:
  • Phone: 717-367-1121
  • Fax: 717-367-5813
Mailing address:
  • Phone: 717-367-1121
  • Fax: 717-367-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number131502
License Number StatePA

VIII. Authorized Official

Name: MS. PAMELA FORMICA
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 717-367-1121