Provider Demographics
NPI:1356471197
Name:MASONIC HOMES OF THE GRAND LODGE OF FREE & ACCEPTED MASONS
Entity Type:Organization
Organization Name:MASONIC HOMES OF THE GRAND LODGE OF FREE & ACCEPTED MASONS
Other - Org Name:MASONIC VILLAGE AT ELIZABETHTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PRAZENICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-367-1121
Mailing Address - Street 1:1 MASONIC DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-2199
Mailing Address - Country:US
Mailing Address - Phone:717-367-1121
Mailing Address - Fax:717-367-5813
Practice Address - Street 1:581 FREEMASON DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-3187
Practice Address - Country:US
Practice Address - Phone:717-367-1121
Practice Address - Fax:717-367-5813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
PA301790320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000027230036Medicaid
PA1000027230026Medicaid