Healthcare Provider Details

I. General information

NPI: 1740293083
Provider Name (Legal Business Name): THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 09/20/2021
Certification Date: 09/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24090 SMILEY RD STE 200
NISSWA MN
56468
US

IV. Provider business mailing address

24090 SMILEY RD STE 200
NISSWA MN
56468-2946
US

V. Phone/Fax

Practice location:
  • Phone: 218-963-9842
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: ERIC VANDENHULL
Title or Position: EXECUTIVE VP
Credential:
Phone: 605-362-3900