Basic Information
Provider Information | |||||||||
NPI: | 1275755514 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GOOD SHEPHERD PERSONAL CARE LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 915 N WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | BASTROP | ||||||||
State: | LA | ||||||||
PostalCode: | 712203007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182830220 | ||||||||
FaxNumber: | 3182830210 | ||||||||
Practice Location | |||||||||
Address1: | 915 N WASHINGTON ST | ||||||||
Address2: |   | ||||||||
City: | BASTROP | ||||||||
State: | LA | ||||||||
PostalCode: | 712203007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182830220 | ||||||||
FaxNumber: | 3182830210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 04/19/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | HENRY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 3182830220 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 6936 | LA | N |   | Agencies | Home Health |   | 253Z00000X |   |   | Y |   | Agencies | In Home Supportive Care |   |
ID Information
ID | Type | State | Issuer | Description | 1098973 | 05 | LA |   | MEDICAID |