Provider Demographics
NPI:1750659199
Name:GOOD SHEPHERD MANOR INC
Entity Type:Organization
Organization Name:GOOD SHEPHERD MANOR INC
Other - Org Name:THOMAS HERBSTRITT HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-472-3700
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:
Mailing Address - City:MOMENCE
Mailing Address - State:IL
Mailing Address - Zip Code:60954-0260
Mailing Address - Country:US
Mailing Address - Phone:815-472-3700
Mailing Address - Fax:815-472-6086
Practice Address - Street 1:4003 N. ROUTES 1 & 17
Practice Address - Street 2:
Practice Address - City:MOMENCE
Practice Address - State:IL
Practice Address - Zip Code:60954-0260
Practice Address - Country:US
Practice Address - Phone:815-472-3700
Practice Address - Fax:815-472-6086
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD MANOR INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0051466315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities