Provider Demographics
NPI:1790045136
Name:GOOD SHEPHERD TRANSPORT
Entity Type:Organization
Organization Name:GOOD SHEPHERD TRANSPORT
Other - Org Name:GOOD SHEPHERD TRANSPORT LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-544-7015
Mailing Address - Street 1:5720 GATEWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-1891
Mailing Address - Country:US
Mailing Address - Phone:513-823-2021
Mailing Address - Fax:513-488-1934
Practice Address - Street 1:5720 GATEWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-1891
Practice Address - Country:US
Practice Address - Phone:513-823-2021
Practice Address - Fax:513-488-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-19
Last Update Date:2012-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31-583-5343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)