Healthcare Provider Details

I. General information

NPI: 1306879580
Provider Name (Legal Business Name): LTC HEALTHCARE SHEPARD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 05/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 WOODLAND PARK DR
SHEPHERD TX
77371-6497
US

IV. Provider business mailing address

5895 WINDWARD PARKWAY SUITE 200
ALPHARETTA GA
30005-8805
US

V. Phone/Fax

Practice location:
  • Phone: 936-628-3388
  • Fax: 936-628-6387
Mailing address:
  • Phone: 770-870-2813
  • Fax: 770-870-2892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number115618
License Number StateTX

VIII. Authorized Official

Name: MR. DOUGLAS K MITTLEIDER
Title or Position: PRESIDENT
Credential:
Phone: 770-870-2813