Provider Demographics
NPI:1174901375
Name:THE LUTHERAN HOME FOR THE AGED D/B/A THE VILLAGE AT LUTHER SQUARE
Entity type:Organization
Organization Name:THE LUTHERAN HOME FOR THE AGED D/B/A THE VILLAGE AT LUTHER SQUARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:P
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:814-456-5433
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:814-456-5433
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:814-456-5433
Practice Address - Fax:814-456-0383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA314000000X314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility