Healthcare Provider Details

I. General information

NPI: 1457453334
Provider Name (Legal Business Name): GOOD SHEPHERD HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 COLUMBUS AVE
FOSTORIA OH
44830-3255
US

IV. Provider business mailing address

725 COLUMBUS AVE
FOSTORIA OH
44830-3255
US

V. Phone/Fax

Practice location:
  • Phone: 419-435-1801
  • Fax: 419-435-1594
Mailing address:
  • Phone: 419-435-1801
  • Fax: 419-435-1594

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0982N
License Number StateOH

VIII. Authorized Official

Name: MR. CHRISTOPHER P WIDMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 419-937-1801