Healthcare Provider Details

I. General information

NPI: 1376897207
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

801 RIDGE PIKE
LAFAYETTE HILL PA
19444-1744
US

IV. Provider business mailing address

581 FREEMASON DR
ELIZABETHTOWN PA
17022-3187
US

V. Phone/Fax

Practice location:
  • Phone: 610-825-6100
  • Fax: 610-828-2803
Mailing address:
  • Phone: 717-367-1121
  • Fax: 717-367-5813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number137102
License Number StatePA

VIII. Authorized Official

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