Basic Information
| Provider Information | |||||||||
| NPI: | 1134368459 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRIENDS OF GOOD SHEPHERD MANOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 GOOD MANOR RD | ||||||||
| Address2: | PO BOX 1029 | ||||||||
| City: | LUCASVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892861 | ||||||||
| FaxNumber: | 7402894355 | ||||||||
| Practice Location | |||||||||
| Address1: | 374 GOOD MANOR RD | ||||||||
| Address2: | |||||||||
| City: | LUCASVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892861 | ||||||||
| FaxNumber: | 7402894355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2009 | ||||||||
| LastUpdateDate: | 02/10/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOWLING | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7402892861 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315P00000X | Y | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded |
ID Information
| ID | Type | State | Issuer | Description | 2234344 | 05 | OH | MEDICAID |