Provider Demographics
NPI:1093459372
Name:DE GOOD SHEPHARD SENIOR LIVING
Entity Type:Organization
Organization Name:DE GOOD SHEPHARD SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:IJEOMA
Authorized Official - Last Name:EZEKWE-ANYA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:170-439-0646
Mailing Address - Street 1:14809 BRIDGEWATER LN
Mailing Address - Street 2:
Mailing Address - City:MINT HILL
Mailing Address - State:NC
Mailing Address - Zip Code:28227-8514
Mailing Address - Country:US
Mailing Address - Phone:980-299-0010
Mailing Address - Fax:980-299-3006
Practice Address - Street 1:14809 BRIDGEWATER LN
Practice Address - Street 2:
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-8514
Practice Address - Country:US
Practice Address - Phone:980-299-0010
Practice Address - Fax:980-299-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-23
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility