Healthcare Provider Details

I. General information

NPI: 1093877045
Provider Name (Legal Business Name): GOOD SHEPHERD CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17314 KEDZIE AVE
HAZEL CREST IL
60429-1619
US

IV. Provider business mailing address

17314 KEDZIE AVE
HAZEL CREST IL
60429-1619
US

V. Phone/Fax

Practice location:
  • Phone: 708-335-0020
  • Fax: 708-335-0022
Mailing address:
  • Phone: 708-335-0020
  • Fax: 708-335-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number008118
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number008118
License Number StateIL

VIII. Authorized Official

Name: MR. BRENDAN P MCCORMICK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 708-335-0020