Provider Demographics
NPI:1891432852
Name:GOOD SHEPHERD MANOR LLC
Entity Type:Organization
Organization Name:GOOD SHEPHERD MANOR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:CAPILI
Authorized Official - Last Name:MACHARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-991-6939
Mailing Address - Street 1:302 NORDINA ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6022
Mailing Address - Country:US
Mailing Address - Phone:909-798-2876
Mailing Address - Fax:909-793-1188
Practice Address - Street 1:302 NORDINA ST
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6022
Practice Address - Country:US
Practice Address - Phone:909-798-2876
Practice Address - Fax:909-793-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness