Organization
GOOD SHEPHERD MANOR GROUPS HOMES, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. BRUCE ROBERT FITZPATRICK (PRESIDENT)
(815) 472-3700
Entity
Organization
Contact information
Practice address
4129 N STATE ROUTES 1 & 17, MOMENCE, IL 60954
(815) 472-3700
(815) 472-6086
Mailing address
PO BOX 260, 4129 N STATE ROUTES 1 & 17, MOMENCE, IL 60954-0260
(815) 472-3700
(815) 472-6086
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
0041913
IL
315P00000X
Intellectual Disabilities Intermediate Care Facility
41905
IL
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
96S015
IL
Other
Enumeration date
03/18/2010
Last updated
03/18/2010
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