1114049780 NPI number — SHEPHERD SUPPORT SERVICES, LLC

Table of content: (NPI 1114049780)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114049780 NPI number — SHEPHERD SUPPORT SERVICES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHEPHERD SUPPORT SERVICES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114049780
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3351 W DRIFTWOOD CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65807-8151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-866-1559
Provider Business Mailing Address Fax Number:
417-823-0716

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 OLD AIRPORT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65708-9182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-236-0199
Provider Business Practice Location Address Fax Number:
417-236-0220
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUNTER
Authorized Official First Name:
HENRY
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
417-489-6300

Provider Taxonomy Codes

  • Taxonomy code: 261QA0600X , with the licence number:  690 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com