Provider Demographics
NPI:1760474472
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 LAFAYETTE HILL
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 1:1 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 1:801 RIDGE PIKE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE HILL
Practice Address - State:PA
Practice Address - Zip Code:19444-1723
Practice Address - Country:US
Practice Address - Phone:610-825-6100
Practice Address - Fax:610-828-2803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA144400-DPW310400000X
PA137102-DOH313M00000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0001722000OtherKEYSTONE HEALTH PLAN-IBC
PA10000027230032Medicaid
PA10000027230032Medicaid