Provider Demographics
NPI:1477620086
Name:PORTRAITS OF LIFE ADULT DAY SERVICES, INC.
Entity Type:Organization
Organization Name:PORTRAITS OF LIFE ADULT DAY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CONSTANCE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:EISENHAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-360-7074
Mailing Address - Street 1:419 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:LYKENS
Mailing Address - State:PA
Mailing Address - Zip Code:17048
Mailing Address - Country:US
Mailing Address - Phone:717-453-9355
Mailing Address - Fax:717-453-0846
Practice Address - Street 1:419 MARKET STREET
Practice Address - Street 2:
Practice Address - City:LYKENS
Practice Address - State:PA
Practice Address - Zip Code:17048-1316
Practice Address - Country:US
Practice Address - Phone:717-453-9355
Practice Address - Fax:717-453-0846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA232830261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01732517Medicaid