Provider Demographics
NPI:1912110925
Name:FRIENDS OF GOOD SHEPHERD MANOR
Entity Type:Organization
Organization Name:FRIENDS OF GOOD SHEPHERD MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:BRENDA
Authorized Official - Last Name:BOWLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-289-2861
Mailing Address - Street 1:PO BOX 1029
Mailing Address - Street 2:
Mailing Address - City:LUCASVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45648-1029
Mailing Address - Country:US
Mailing Address - Phone:740-289-2861
Mailing Address - Fax:740-289-3916
Practice Address - Street 1:374 GOOD MANOR RD.
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-1029
Practice Address - Country:US
Practice Address - Phone:740-289-2861
Practice Address - Fax:740-289-3916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6610055315P00000X
OH6610153315P00000X
OH6610306315P00000X
OH6600173320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0830364Medicaid