Healthcare Provider Details

I. General information

NPI: 1669890653
Provider Name (Legal Business Name): THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2014
Last Update Date: 04/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 COUNTY ROAD 12B
PARK RIVER ND
58270-4134
US

IV. Provider business mailing address

PO BOX 5038
SIOUX FALLS SD
57117-5038
US

V. Phone/Fax

Practice location:
  • Phone: 701-284-7115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: RAYE NAE NYLANDER
Title or Position: EXECUTIVE VP
Credential:
Phone: 605-362-3100