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General NPI Number Information
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NPI Number | 1912110925
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Entity Type | Organization
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Legal Business Name | FRIENDS OF GOOD SHEPHERD MANOR
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 02/11/2009
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Provider Practice Location Address
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Address Line | 374 GOOD MANOR RD.
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City | LUCASVILLE
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State | OH
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Zip | 45648-1029
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Country | US
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Telephone | 740-289-2861
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Fax | 740-289-3916
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Provider Business Mailing Address
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Address Line | PO BOX 1029
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City | LUCASVILLE
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State | OH
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Zip | 45648-1029
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Country | US
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Telephone | 740-289-2861
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Fax | 740-289-3916
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MS. JACKIE BRENDA BOWLING
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Credential |
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Telephone | 740-289-2861
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 6610055
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License Number State | OH
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Taxonomy #2
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 6610153
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License Number State | OH
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Taxonomy #3
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 6610306
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License Number State | OH
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Taxonomy #4
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number | 6600173
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License Number State | OH
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