Provider Demographics
NPI:1457453334
Name:GOOD SHEPHERD HOME
Entity Type:Organization
Organization Name:GOOD SHEPHERD HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:P
Authorized Official - Last Name:WIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-937-1801
Mailing Address - Street 1:725 COLUMBUS AVE
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830-3255
Mailing Address - Country:US
Mailing Address - Phone:419-435-1801
Mailing Address - Fax:419-435-1594
Practice Address - Street 1:725 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830-3255
Practice Address - Country:US
Practice Address - Phone:419-435-1801
Practice Address - Fax:419-435-1594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0982N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3293921Medicaid
OH3293921Medicaid