Basic Information
| Provider Information | |||||||||
| NPI: | 1912110925 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRIENDS OF GOOD SHEPHERD MANOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1029 | ||||||||
| Address2: | |||||||||
| City: | LUCASVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456481029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892861 | ||||||||
| FaxNumber: | 7402893916 | ||||||||
| Practice Location | |||||||||
| Address1: | 374 GOOD MANOR RD. | ||||||||
| Address2: | |||||||||
| City: | LUCASVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456481029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402892861 | ||||||||
| FaxNumber: | 7402893916 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2007 | ||||||||
| LastUpdateDate: | 02/11/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOWLING | ||||||||
| AuthorizedOfficialFirstName: | JACKIE | ||||||||
| AuthorizedOfficialMiddleName: | BRENDA | ||||||||
| 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 | 6610055 | OH | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded | 315P00000X | 6610153 | OH | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded | 315P00000X | 6610306 | OH | N | Nursing & Custodial Care Facilities | Intermediate Care Facility, Mentally Retarded | 320900000X | 6600173 | OH | Y | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 0830364 | 05 | OH | MEDICAID |