Provider Demographics
NPI:1023016698
Name:BRETHREN VILLAGE
Entity type:Organization
Organization Name:BRETHREN VILLAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF FINANCE
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-581-4234
Mailing Address - Street 1:3001 LITITZ PIKE
Mailing Address - Street 2:PO BOX 5093
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17606-5093
Mailing Address - Country:US
Mailing Address - Phone:717-569-2657
Mailing Address - Fax:717-581-4400
Practice Address - Street 1:3001 LITITZ PIKE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17606-5093
Practice Address - Country:US
Practice Address - Phone:717-569-2657
Practice Address - Fax:717-581-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01009109Medicaid
397298Medicare ID - Type Unspecified