Healthcare Provider Details

I. General information

NPI: 1255632014
Provider Name (Legal Business Name): GOOD SHEPHARD ADULT SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10537 DAY LILY DR
HAMPTON GA
30228-6138
US

IV. Provider business mailing address

10537 DAY LILY DR
HAMPTON GA
30228-6138
US

V. Phone/Fax

Practice location:
  • Phone: 678-817-3636
  • Fax: 678-817-3636
Mailing address:
  • Phone: 678-817-3636
  • Fax: 678-817-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number031012731
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number031012731
License Number StateGA

VIII. Authorized Official

Name: MS. VERLINCIA CUYLER
Title or Position: CEO
Credential:
Phone: 678-817-3636