Provider Demographics
NPI:1396862314
Name:GOOD SHEPHERD VILLAGE LLC
Entity Type:Organization
Organization Name:GOOD SHEPHERD VILLAGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:STEFFANNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-322-1911
Mailing Address - Street 1:422 N BURNETT RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-4821
Mailing Address - Country:US
Mailing Address - Phone:937-322-1911
Mailing Address - Fax:937-322-8606
Practice Address - Street 1:422 N BURNETT RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-4821
Practice Address - Country:US
Practice Address - Phone:937-322-1911
Practice Address - Fax:937-322-8606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2793314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2265052Medicaid
OH2265052Medicaid