Provider Demographics
NPI:1396079711
Name:GOOD SHEPHERD FAMILY CLINIC INC
Entity type:Organization
Organization Name:GOOD SHEPHERD FAMILY CLINIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-335-5022
Mailing Address - Street 1:112 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-7426
Mailing Address - Country:US
Mailing Address - Phone:417-335-5022
Mailing Address - Fax:417-335-5044
Practice Address - Street 1:112 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7426
Practice Address - Country:US
Practice Address - Phone:417-335-5022
Practice Address - Fax:417-335-5044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-01
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007021133207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty