Provider Demographics
NPI:1326046699
Name:LEBANON VALLEY BRETHREN HOME
Entity Type:Organization
Organization Name:LEBANON VALLEY BRETHREN HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO, VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:F
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-838-5406
Mailing Address - Street 1:1200 GRUBB RD
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:PA
Mailing Address - Zip Code:17078-3514
Mailing Address - Country:US
Mailing Address - Phone:717-838-5406
Mailing Address - Fax:717-641-0073
Practice Address - Street 1:1200 GRUBB RD
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:PA
Practice Address - Zip Code:17078-3514
Practice Address - Country:US
Practice Address - Phone:717-838-5406
Practice Address - Fax:717-641-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA380602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1002291290002Medicaid
PA395437Medicare ID - Type Unspecified