Healthcare Provider Details

I. General information

NPI: 1124547146
Provider Name (Legal Business Name): GOOD SAMARITAN SUPPORTED LIVING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2017
Last Update Date: 09/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 MAWYER DR
COLUMBUS OH
43085-5403
US

IV. Provider business mailing address

616 MAWYER DR
COLUMBUS OH
43085-5403
US

V. Phone/Fax

Practice location:
  • Phone: 614-893-0579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number318641
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARIA THERESA YEBRA VILLANUEVA
Title or Position: RN MANAGER
Credential: RN
Phone: 614-893-0579