Provider Demographics
NPI:1750689113
Name:GOOD SHEPHERD REHABILITATIONS
Entity Type:Organization
Organization Name:GOOD SHEPHERD REHABILITATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRENE JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOB
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:702-380-1060
Mailing Address - Street 1:4275 BURNHAM AVE
Mailing Address - Street 2:SUITE 255
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-8204
Mailing Address - Country:US
Mailing Address - Phone:702-380-1060
Mailing Address - Fax:
Practice Address - Street 1:4275 BURNHAM AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-8204
Practice Address - Country:US
Practice Address - Phone:702-380-1060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRC520261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1702161Medicaid