Healthcare Provider Details

I. General information

NPI: 1811905904
Provider Name (Legal Business Name): GOOD SHEPHERD CARE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 W CLAY RD
VERSAILLES MO
65084-9314
US

IV. Provider business mailing address

1101 W CLAY RD
VERSAILLES MO
65084-9314
US

V. Phone/Fax

Practice location:
  • Phone: 573-378-5411
  • Fax: 573-378-5415
Mailing address:
  • Phone: 573-378-5411
  • Fax: 573-378-5415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031255
License Number StateMO

VIII. Authorized Official

Name: MRS. REBECCA MAY MATHIOT
Title or Position: FINANCIAL MANAGER
Credential:
Phone: 573-378-5411