Healthcare Provider Details

I. General information

NPI: 1972856151
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: 10/25/2012
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 TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number000634A
License Number StatePA

VIII. Authorized Official

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