Healthcare Provider Details

I. General information

NPI: 1235106725
Provider Name (Legal Business Name): GOOD SHEPHERD HOME, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 E BRONSON RD
SEYMOUR WI
54165-1040
US

IV. Provider business mailing address

607 BRONSON ROAD
SEYMOUR WI
54165
US

V. Phone/Fax

Practice location:
  • Phone: 920-833-6856
  • Fax: 920-833-1846
Mailing address:
  • Phone: 920-833-6856
  • Fax: 920-833-1846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number1924
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2659
License Number StateWI

VIII. Authorized Official

Name: DEBORAH A CAPTAIN
Title or Position: EXECUTIVE DIRECTOR
Credential: RN NHA
Phone: 920-833-6856