Provider Demographics
NPI:1508869652
Name:LAFAYETTE MANOR, INC
Entity Type:Organization
Organization Name:LAFAYETTE MANOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSING HOME ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KETTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:724-430-4848
Mailing Address - Street 1:147 LAFAYETTE MANOR ROAD
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15401
Mailing Address - Country:US
Mailing Address - Phone:724-430-4848
Mailing Address - Fax:724-430-1881
Practice Address - Street 1:147 LAFAYETTE MANOR ROAD
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401-8900
Practice Address - Country:US
Practice Address - Phone:724-430-4848
Practice Address - Fax:724-430-1881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA409610310400000X
PA120202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0544OtherBLUECROSS PROVIDER NUMBER
PA0007479900003Medicaid
PA0007479900003Medicaid