Healthcare Provider Details

I. General information

NPI: 1174152565
Provider Name (Legal Business Name): GOOD SHEPHERD SENIOR SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20535 CAMPAIGN DR APT 30C
CARSON CA
90746-3425
US

IV. Provider business mailing address

20535 CAMPAIGN DR APT 30C
CARSON CA
90746-3425
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 424-344-2337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MARCELLAS LACARL JOHNSON
Title or Position: CEO
Credential:
Phone: 310-654-8007