Provider Demographics
NPI:1841285939
Name:GOOD SHEPHERD-FAIRVIEW HOME, INC.
Entity type:Organization
Organization Name:GOOD SHEPHERD-FAIRVIEW HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:LINUS
Authorized Official - Last Name:TIGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:604-724-2477
Mailing Address - Street 1:80 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13904-1199
Mailing Address - Country:US
Mailing Address - Phone:607-724-2477
Mailing Address - Fax:607-724-0957
Practice Address - Street 1:80 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13904-1199
Practice Address - Country:US
Practice Address - Phone:607-724-2477
Practice Address - Fax:607-724-0957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-14
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0301305N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00474699Medicaid
NYM6563Medicare ID - Type UnspecifiedRR MEDICARE
NY81066AMedicare ID - Type UnspecifiedUMD
NY335527Medicare ID - Type Unspecified