MEDICARE: SHEPHERDS BAPTIST MINISTRIES 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1407209109
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHEPHERDS BAPTIST MINISTRIES INC

Provider Business Mailing Address
First Line	:	1805 15TH AVE
Second Line	:
City	:	UNION GROVE
State	:	WI
Zip	:	53182-1527
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 15TH AVE
Second Line	:
City	:	UNION GROVE
State	:	WI
Zip	:	53182-1527
Country	:	US
Telephone Number	:	262-878-5620
Fax Number	:	262-878-9285

Authorized Official
Title or Position	:	CONTROLLER
Name	:	KARYN BORUCKI
Credential	:
Telephone Number	:	262-878-5620

Provider Enumeration Date	:	07/18/2016
Last Update Date	:	07/18/2016

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