Provider Demographics
NPI:1508257148
Name:GOOD SHEPHERD ASSISTANT LIVING
Entity Type:Organization
Organization Name:GOOD SHEPHERD ASSISTANT LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-223-1858
Mailing Address - Street 1:703 N HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-2933
Mailing Address - Country:US
Mailing Address - Phone:936-327-9956
Mailing Address - Fax:
Practice Address - Street 1:703 N HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-2933
Practice Address - Country:US
Practice Address - Phone:936-327-9956
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139482310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility