MEDICARE: GOOD SHEPHERD REHAB INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	20071354581	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386933315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOOD SHEPHERD REHAB INC.

Provider Business Mailing Address
First Line	:	4275 BURNHAM AVE STE 255
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-8204
Country	:	US
Telephone Number	:	702-380-1060
Fax Number	:	702-380-1081

Provider Business Practice Location Address
First Line	:	4275 BURNHAM AVE STE 255
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-8204
Country	:	US
Telephone Number	:	702-380-1060
Fax Number	:	702-380-1081

Authorized Official
Title or Position	:	CEO
Name	:	MR. RAUL ABEJUELA
Credential	:
Telephone Number	:	702-893-3333

Provider Enumeration Date	:	03/30/2011
Last Update Date	:	03/30/2011

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