Provider Demographics
NPI:1508952409
Name:GOOD SHEPHERD HOME CARE AND HOSPICE, INC.
Entity Type:Organization
Organization Name:GOOD SHEPHERD HOME CARE AND HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-277-6474
Mailing Address - Street 1:5383 S 900 E
Mailing Address - Street 2:STE 102
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7249
Mailing Address - Country:US
Mailing Address - Phone:801-277-6474
Mailing Address - Fax:801-277-6475
Practice Address - Street 1:5383 S 900 E
Practice Address - Street 2:STE 102
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117-7249
Practice Address - Country:US
Practice Address - Phone:801-277-6474
Practice Address - Fax:801-277-6475
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD HOMECARE AND HOSPICE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-05
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2005-HOSPICE-54976251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT810582329002Medicaid
UT810582329002Medicaid