=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730489360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHEPHERD'S HOME CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2010
-----------------------------------------------------
Last Update Date | 10/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1953 W JAKE ALEXANDER BLVD 2
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-680-4321
-----------------------------------------------------
Fax | 704-680-4321
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1953 JAKE ALEXANDER BLVD W D
-----------------------------------------------------
City | SALISBURY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28147-1166
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-680-4321
-----------------------------------------------------
Fax | 704-680-4321
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. CLARY L PHELPS JR.
-----------------------------------------------------
Credential | DMIN
-----------------------------------------------------
Telephone | 704-267-3414
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | HC4200
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------