Basic Information
| Provider Information | |||||||||
| NPI: | 1740402072 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GOOD SHEPHERD PERSONAL CARE SERVICE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 206 W MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712203756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182830220 | ||||||||
| FaxNumber: | 3182830210 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 W MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712203756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182830220 | ||||||||
| FaxNumber: | 3182830210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 06/18/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | HENRY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3182830220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 6958 | LA | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1706892 | 05 | LA | MEDICAID |