=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114049780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHEPHERD SUPPORT SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 OLD AIRPORT RD
-----------------------------------------------------
City | MONETT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65708-9182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-236-0199
-----------------------------------------------------
Fax | 417-236-0220
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3351 W DRIFTWOOD CT
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65807-8151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-866-1559
-----------------------------------------------------
Fax | 417-823-0716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL MANAGER
-----------------------------------------------------
Name | MR. HENRY DAVID HUNTER JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-489-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number | 690
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------