Basic Information
| Provider Information | |||||||||
| NPI: | 1457573792 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GOOD SHEPHERD PERSONAL CARE LLC | ||||||||
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| 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 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3182830220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
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| 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 | 1098965 | 05 | LA | MEDICAID |