=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174901375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE LUTHERAN HOME FOR THE AGED D/B/A THE VILLAGE AT LUTHER SQUARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2015
-----------------------------------------------------
Last Update Date | 05/08/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 149 W 22ND ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16502-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-456-5433
-----------------------------------------------------
Fax | 814-456-0383
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 149 W 22ND ST
-----------------------------------------------------
City | ERIE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16502-2804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-456-5433
-----------------------------------------------------
Fax | 814-456-0383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | BRADLEY P FOX
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 814-456-5433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 314000000X
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------