Provider Demographics
NPI:1174152565
Name:GOOD SHEPHERD SENIOR SERVICES LLC
Entity type:Organization
Organization Name:GOOD SHEPHERD SENIOR SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARCELLAS
Authorized Official - Middle Name:LACARL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-654-8007
Mailing Address - Street 1:20535 CAMPAIGN DR APT 30C
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-3425
Mailing Address - Country:US
Mailing Address - Phone:424-344-2337
Mailing Address - Fax:
Practice Address - Street 1:20535 CAMPAIGN DR APT 30C
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90746-3425
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-07
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health