MEDICARE: GOOD SHEPHERD GERIATRIC CENTER, 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	103TA0700X	Adult Development & Aging Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639243496
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOOD SHEPHERD GERIATRIC CENTER, INC.

Provider Business Mailing Address
First Line	:	302 2ND ST NE
Second Line	:
City	:	MASON CITY
State	:	IA
Zip	:	50401-3412
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 2ND ST NE
Second Line	:
City	:	MASON CITY
State	:	IA
Zip	:	50401-3412
Country	:	US
Telephone Number	:	641-424-1740
Fax Number	:

Authorized Official
Title or Position	:	BKPR
Name	:	ANNE DEMARIS
Credential	:
Telephone Number	:	641-424-1740

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	08/22/2020

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