Provider Demographics
NPI:1386933315
Name:GOOD SHEPHERD REHAB INC.
Entity type:Organization
Organization Name:GOOD SHEPHERD REHAB INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABEJUELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-893-3333
Mailing Address - Street 1:4275 BURNHAM AVE STE 255
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-8204
Mailing Address - Country:US
Mailing Address - Phone:702-380-1060
Mailing Address - Fax:702-380-1081
Practice Address - Street 1:4275 BURNHAM AVE STE 255
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-8204
Practice Address - Country:US
Practice Address - Phone:702-380-1060
Practice Address - Fax:702-380-1081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-30
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV20071354581261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV001702161Medicaid
NV294507Medicare UPIN