Healthcare Provider Details

I. General information

NPI: 1982154993
Provider Name (Legal Business Name): THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 SAMARITAN CIR
BELINGTON WV
26250-8141
US

IV. Provider business mailing address

4800 W 57TH ST
SIOUX FALLS SD
57108-2239
US

V. Phone/Fax

Practice location:
  • Phone: 304-823-2555
  • Fax: 304-823-3136
Mailing address:
  • Phone: 605-362-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRANT TRIBBLE
Title or Position: EXECUTIVE VP - FINANCE
Credential:
Phone: 605-362-3100