Provider Demographics
NPI:1437607108
Name:SHEPHERD LIVING HOSPICE LLC
Entity Type:Organization
Organization Name:SHEPHERD LIVING HOSPICE LLC
Other - Org Name:FOUR SEASONS HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:TALUKDAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-767-3870
Mailing Address - Street 1:15420 NACOGDOCHES RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-1106
Mailing Address - Country:US
Mailing Address - Phone:210-767-3870
Mailing Address - Fax:
Practice Address - Street 1:15420 NACOGDOCHES RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247
Practice Address - Country:US
Practice Address - Phone:210-767-3870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHEPHERD LIVING HOSPICE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-12
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX016725251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX016725OtherSTATE LICENSE
TX001029813Medicaid