Provider Demographics
NPI:1891407656
Name:SHEPHERD HOME CARE LLC
Entity Type:Organization
Organization Name:SHEPHERD HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMEON
Authorized Official - Middle Name:JOLLY
Authorized Official - Last Name:KPA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-277-8454
Mailing Address - Street 1:7702 N 35TH AVE RM 3
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85051-6508
Mailing Address - Country:US
Mailing Address - Phone:623-268-2542
Mailing Address - Fax:
Practice Address - Street 1:7702 N 35TH AVE RM 3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85051-6508
Practice Address - Country:US
Practice Address - Phone:623-268-2542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-22
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services