Provider Demographics
NPI:1891792354
Name:LUTHERAN HOME FOR THE AGED
Entity Type:Organization
Organization Name:LUTHERAN HOME FOR THE AGED
Other - Org Name:THE VILLAGE AT LUTHER SQUARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:C EO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUSEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-452-3271
Mailing Address - Street 1:149 W 22ND ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2804
Mailing Address - Country:US
Mailing Address - Phone:814-452-3271
Mailing Address - Fax:814-456-0383
Practice Address - Street 1:149 W 22ND ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2804
Practice Address - Country:US
Practice Address - Phone:814-452-3271
Practice Address - Fax:814-456-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-30
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA382602314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0648OtherBLUE CROSS PROVIDER NO.
PA1007767250002Medicaid
PA395672Medicare ID - Type UnspecifiedPROVIDER NUMBER