Provider Demographics
NPI:1275704546
Name:FRIENDS OF GOOD SHEPHERD MANOR
Entity Type:Organization
Organization Name:FRIENDS OF GOOD SHEPHERD MANOR
Other - Org Name:GOOD SHEPHERD MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM CHIEF EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-885-2861
Mailing Address - Street 1:374 GOOD MANOR ROAD
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:374 GOOD MANOR RD.
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648
Practice Address - Country:US
Practice Address - Phone:187-788-5286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0850477Medicaid