=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750908273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOOD SHEPHERD HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2020
-----------------------------------------------------
Last Update Date | 06/30/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 N 31ST AVE STE D311
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85051-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-612-2940
-----------------------------------------------------
Fax | 602-926-7404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10000 N 31ST AVE STE D311
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85051-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-612-2940
-----------------------------------------------------
Fax | 602-926-7404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | FELIMON JOSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 602-612-2940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------