Provider Demographics
NPI:1962661413
Name:GOOD SHEPHERD REHABILITATION INSTITUTE
Entity Type:Organization
Organization Name:GOOD SHEPHERD REHABILITATION INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT
Authorized Official - Prefix:
Authorized Official - First Name:MYRA JUNE
Authorized Official - Middle Name:LUY
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:702-380-1060
Mailing Address - Street 1:4275 BURNHAM AVE
Mailing Address - Street 2:STE 255
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-5488
Mailing Address - Country:US
Mailing Address - Phone:702-380-1060
Mailing Address - Fax:702-380-1081
Practice Address - Street 1:4275 BURNHAM AVE
Practice Address - Street 2:STE 255
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5488
Practice Address - Country:US
Practice Address - Phone:702-380-1060
Practice Address - Fax:702-380-1081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD REHABILITATION CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2073261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV001702161Medicaid
NV294507Medicare PIN