Provider Demographics
NPI:1194876359
Name:GOOD SHEPHERD LUTHERAN HOME OF THE WEST
Entity type:Organization
Organization Name:GOOD SHEPHERD LUTHERAN HOME OF THE WEST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL AFFAIRS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:KACZMARSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-206-4406
Mailing Address - Street 1:600 HOFFMANN DR
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094-6223
Mailing Address - Country:US
Mailing Address - Phone:920-261-3050
Mailing Address - Fax:920-261-8441
Practice Address - Street 1:26489 RANCHO PKWY S
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8326
Practice Address - Country:US
Practice Address - Phone:949-855-8056
Practice Address - Fax:949-600-6116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-15
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320900000X
CO320900000X
OR320900000X
WA320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities