Healthcare Provider Details

I. General information

NPI: 1700100971
Provider Name (Legal Business Name): GOOD SHEPHERD MANOR, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4129 N STATE ROUTES 1 & 17
MOMENCE IL
60954-0260
US

IV. Provider business mailing address

PO BOX 260 4129 N STATE ROUTES 1 & 17
MOMENCE IL
60954-0260
US

V. Phone/Fax

Practice location:
  • Phone: 815-472-3700
  • Fax: 815-472-6086
Mailing address:
  • Phone: 815-472-3700
  • Fax: 815-472-6086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number6-374
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0002865
License Number StateIL

VIII. Authorized Official

Name: MR. BRUCE ROBERT FITZPATRICK
Title or Position: PRESIDENT
Credential:
Phone: 815-472-3700