Provider Demographics
NPI:1235283151
Name:GOOD SHEPHERD HOSPICE, INC.
Entity Type:Organization
Organization Name:GOOD SHEPHERD HOSPICE, INC.
Other - Org Name:GOOD SHEPHERD HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-871-8400
Mailing Address - Street 1:12470 TELECOM DR STE 300W
Mailing Address - Street 2:ATTENTION: COMPLIANCE
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0904
Mailing Address - Country:US
Mailing Address - Phone:813-871-8400
Mailing Address - Fax:813-871-8402
Practice Address - Street 1:3470 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-1946
Practice Address - Country:US
Practice Address - Phone:863-682-0027
Practice Address - Fax:863-682-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50060951251G00000X, 251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL150021000Medicaid
FL101550Medicare Oscar/Certification