Provider Demographics
NPI:1477511442
Name:MASONIC HOMES AT ELIZABETHTOWN GD LDG OF FREE & ACCPTD MASONS PA
Entity Type:Organization
Organization Name:MASONIC HOMES AT ELIZABETHTOWN GD LDG OF FREE & ACCPTD MASONS PA
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:CPA
Authorized Official - Phone:717-367-1121
Mailing Address - Street 1:581 FREEMASON DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-3187
Mailing Address - Country:US
Mailing Address - Phone:717-367-1121
Mailing Address - Fax:717-367-5813
Practice Address - Street 1:1 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2199
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:2006-05-01
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA080101802Medicare PIN
PA513779Medicare PIN