Healthcare Provider Details

I. General information

NPI: 1710082904
Provider Name (Legal Business Name): THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/28/2021
Certification Date: 11/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 21ST ST SE
MANDAN ND
58554-1341
US

IV. Provider business mailing address

201 14TH ST NW
MANDAN ND
58554-2063
US

V. Phone/Fax

Practice location:
  • Phone: 701-663-4274
  • Fax: 701-663-0359
Mailing address:
  • Phone: 701-663-4274
  • Fax: 701-663-0359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1090
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1469241
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier8495
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS
# 3
Identifier1090
Identifier TypeOTHER
Identifier StateND
Identifier IssuerSTATE

VIII. Authorized Official

Name: ERIC VANDEN HULL
Title or Position: VICE PRESIDENT
Credential:
Phone: 605-362-5510