Provider Demographics
NPI:1235106725
Name:GOOD SHEPHERD HOME, LTD
Entity Type:Organization
Organization Name:GOOD SHEPHERD HOME, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:CAPTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:RN NHA
Authorized Official - Phone:920-833-6856
Mailing Address - Street 1:607 BRONSON ROAD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:WI
Mailing Address - Zip Code:54165
Mailing Address - Country:US
Mailing Address - Phone:920-833-6856
Mailing Address - Fax:920-833-1846
Practice Address - Street 1:607 E BRONSON RD
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:WI
Practice Address - Zip Code:54165-1040
Practice Address - Country:US
Practice Address - Phone:920-833-6856
Practice Address - Fax:920-833-1846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-02
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1924310400000X
WI2659314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20108500Medicaid
WI525509Medicare ID - Type Unspecified