Healthcare Provider Details

I. General information

NPI: 1962484022
Provider Name (Legal Business Name): THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 S SEGRAVE ST
DAYTONA BEACH FL
32114-4220
US

IV. Provider business mailing address

PO BOX 5038
SIOUX FALLS SD
57117-5038
US

V. Phone/Fax

Practice location:
  • Phone: 386-253-6791
  • Fax: 386-258-3842
Mailing address:
  • Phone: 605-362-3100
  • Fax: 605-362-3265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. ERIC VANDEN HULL
Title or Position: VP, FINANCE
Credential:
Phone: 605-362-3100