Provider Demographics
NPI:1700100971
Name:GOOD SHEPHERD MANOR, INC
Entity Type:Organization
Organization Name:GOOD SHEPHERD MANOR, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:FITZPATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-472-3700
Mailing Address - Street 1:PO BOX 260
Mailing Address - Street 2:4129 N STATE ROUTES 1 & 17
Mailing Address - City:MOMENCE
Mailing Address - State:IL
Mailing Address - Zip Code:60954-0260
Mailing Address - Country:US
Mailing Address - Phone:815-472-3700
Mailing Address - Fax:815-472-6086
Practice Address - Street 1:4129 N STATE ROUTES 1 & 17
Practice Address - Street 2:
Practice Address - City:MOMENCE
Practice Address - State:IL
Practice Address - Zip Code:60954-0260
Practice Address - Country:US
Practice Address - Phone:815-472-3700
Practice Address - Fax:815-472-6086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-17
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL6-374251C00000X
IL0002865311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home