Healthcare Provider Details

I. General information

NPI: 1972503779
Provider Name (Legal Business Name): GOOD SHEPHERD REHABILITATION AND NURSING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PLANTATION DR
JAFFREY NH
03452-6631
US

IV. Provider business mailing address

20 PLANTATION DR
JAFFREY NH
03452-6631
US

V. Phone/Fax

Practice location:
  • Phone: 603-532-8762
  • Fax: 603-532-6057
Mailing address:
  • Phone: 603-532-8762
  • Fax: 603-532-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number01621
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier30003252
Identifier TypeMEDICAID
Identifier StateNH
Identifier Issuer

VIII. Authorized Official

Name: MRS. ANN E. NUNN
Title or Position: ADMINISTRATOR
Credential: RN, MHA
Phone: 603-532-8762