Provider Demographics
NPI:1871584409
Name:SOUDERTON MENNONITE HOMES
Entity type:Organization
Organization Name:SOUDERTON MENNONITE HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:BRUBAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-368-4438
Mailing Address - Street 1:207 W SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:SOUDERTON
Mailing Address - State:PA
Mailing Address - Zip Code:18964-2054
Mailing Address - Country:US
Mailing Address - Phone:215-723-9881
Mailing Address - Fax:215-723-1442
Practice Address - Street 1:207 W SUMMIT ST
Practice Address - Street 2:
Practice Address - City:SOUDERTON
Practice Address - State:PA
Practice Address - Zip Code:18964-2054
Practice Address - Country:US
Practice Address - Phone:215-723-9881
Practice Address - Fax:215-723-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-02
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA050202314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010170020001Medicaid
PA395634Medicare ID - Type Unspecified