Provider Demographics
NPI:1831187079
Name:BRADFORD ECUMENICAL HOME INC
Entity type:Organization
Organization Name:BRADFORD ECUMENICAL HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:814-368-5648
Mailing Address - Street 1:100 SAINT FRANCIS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701
Mailing Address - Country:US
Mailing Address - Phone:814-368-5648
Mailing Address - Fax:814-368-4642
Practice Address - Street 1:100 SAINT FRANCIS DRIVE
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701
Practice Address - Country:US
Practice Address - Phone:814-368-5648
Practice Address - Fax:814-368-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-12
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA281402314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011692000001Medicaid
PA395908OtherMEDICARE