Basic Information
| Provider Information | |||||||||
| NPI: | 1306879580 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LTC HEALTHCARE SHEPARD INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WOODLAND PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5895 WINDWARD PARKWAY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300058805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708702813 | ||||||||
| FaxNumber: | 7708702892 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 WOODLAND PARK DR | ||||||||
| Address2: | |||||||||
| City: | SHEPHERD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773716497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9366283388 | ||||||||
| FaxNumber: | 9366286387 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2006 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITTLEIDER | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7708702813 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 115618 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001001399 | 05 | TX | MEDICAID |