Healthcare Provider Details

I. General information

NPI: 1467436121
Provider Name (Legal Business Name): THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 SOUTH HWY 80
BENSON AZ
85602-6988
US

IV. Provider business mailing address

PO BOX 5038 4800 WEST 57TH STREET
SIOUX FALLS SD
57117-5038
US

V. Phone/Fax

Practice location:
  • Phone: 520-586-2372
  • Fax: 520-586-7003
Mailing address:
  • Phone: 605-362-3100
  • Fax: 605-362-3265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. RAYE NAE NYLANDER
Title or Position: CFO
Credential:
Phone: 605-362-3100