Provider Demographics
NPI:1861492258
Name:ODD FELLOWS HOME OF PENNSYLVANIA
Entity type:Organization
Organization Name:ODD FELLOWS HOME OF PENNSYLVANIA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEON
Authorized Official - Middle Name:S
Authorized Official - Last Name:STAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-777-5990
Mailing Address - Street 1:999 W HARRISBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17057-4801
Mailing Address - Country:US
Mailing Address - Phone:717-944-3351
Mailing Address - Fax:717-948-1510
Practice Address - Street 1:999 W HARRISBURG PIKE
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:PA
Practice Address - Zip Code:17057-4801
Practice Address - Country:US
Practice Address - Phone:717-944-3351
Practice Address - Fax:717-948-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA150302314000000X
PA343360310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0755179Medicaid
PA0755179Medicaid