Healthcare Provider Details

I. General information

NPI: 1740393693
Provider Name (Legal Business Name): GOOD SHEPHERD REHABILITATION AGENCY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6091 THOR DR
HUNTINGTON BEACH CA
92647-2400
US

IV. Provider business mailing address

6091 THOR DR
HUNTINGTON BEACH CA
92647-2400
US

V. Phone/Fax

Practice location:
  • Phone: 714-269-7986
  • Fax: 714-799-4322
Mailing address:
  • Phone: 714-269-7986
  • Fax: 714-799-4322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. SHENOUDA BAHGAT SALIB
Title or Position: PHYSICAL THERAPIST / PRESIDENT
Credential: RPT
Phone: 714-269-7986