MEDICARE: SHEPHERD IMPACT SERVICES INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1083805576
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEPHERD IMPACT SERVICES INC.

Provider Business Mailing Address
First Line	:	2415 LAKEWOOD DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6801
Country	:	US
Telephone Number	:	214-734-3362
Fax Number	:	972-206-2569

Provider Business Practice Location Address
First Line	:	2415 LAKEWOOD DR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-6801
Country	:	US
Telephone Number	:	214-734-3362
Fax Number	:	972-206-2569

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. DAN AWUKU
Credential	:
Telephone Number	:	214-734-3362

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	08/08/2007

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