1194807677 NPI number — THE SHEPARD'S HOUSE, LLC

Table of content: (NPI 1194807677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194807677 NPI number — THE SHEPARD'S HOUSE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE SHEPARD'S HOUSE, 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:
1194807677
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6612 E WT HARRIS BLVD
Provider Second Line Business Mailing Address:
SUITE I
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28215-5134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-494-8712
Provider Business Mailing Address Fax Number:
704-494-8713

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6612 E WT HARRIS BLVD
Provider Second Line Business Practice Location Address:
SUITE I
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28215-5134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-494-8712
Provider Business Practice Location Address Fax Number:
704-494-8713
Provider Enumeration Date:
10/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BATTLE
Authorized Official First Name:
DARYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENCY DIRECTOR
Authorized Official Telephone Number:
704-494-8712

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  6601534 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3418427 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6601543 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com