Provider Demographics
NPI:1841470986
Name:GOOD SHEPHERD FAMILY CARE HOME, LLC
Entity type:Organization
Organization Name:GOOD SHEPHERD FAMILY CARE HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:TOMAS
Authorized Official - Last Name:BALASSU-PASCUA
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN
Authorized Official - Phone:336-644-0752
Mailing Address - Street 1:3592 HANCOCK DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-9157
Mailing Address - Country:US
Mailing Address - Phone:336-644-0752
Mailing Address - Fax:336-643-9731
Practice Address - Street 1:2810 FLEMING ROAD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410
Practice Address - Country:US
Practice Address - Phone:336-644-0752
Practice Address - Fax:336-643-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-754311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805363Medicaid