Provider Demographics
NPI:1811905904
Name:GOOD SHEPHERD CARE CENTER
Entity type:Organization
Organization Name:GOOD SHEPHERD CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:MATHIOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-378-5411
Mailing Address - Street 1:1101 W CLAY RD
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:MO
Mailing Address - Zip Code:65084-9314
Mailing Address - Country:US
Mailing Address - Phone:573-378-5411
Mailing Address - Fax:573-378-5415
Practice Address - Street 1:1101 W CLAY RD
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:MO
Practice Address - Zip Code:65084-9314
Practice Address - Country:US
Practice Address - Phone:573-378-5411
Practice Address - Fax:573-378-5415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD NURSING HOME DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-04
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QX0100X, 261QP2000X
MO031255314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101487502Medicaid
MO124739OtherHEALTHLINK
MO110693OtherBLUE CROSS OF MISSOURI
MO265528Medicare Oscar/Certification