MEDICARE: GOOD SHEPHERD REHABILITATIONS

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	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)	RC520	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	:	1750689113
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOOD SHEPHERD REHABILITATIONS

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

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

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	IRENE JOY GOB
Credential	:	RN
Telephone Number	:	702-380-1060

Provider Enumeration Date	:	03/09/2011
Last Update Date	:	06/09/2011

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