MEDICARE: THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	332BN1400X	Nursing Facility Supplies (DME)
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)
3	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01453	OTHER	ID	BLUE CROSS IDAHO
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	000010012984	OTHER	ID	REGENCE BLUE SHIELD

General Provider Information

NPI Number	:	1366432023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Provider Business Mailing Address
First Line	:	PO BOX 5038
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57117-5038
Country	:	US
Telephone Number	:	605-362-3100
Fax Number	:	605-362-3265

Provider Business Practice Location Address
First Line	:	840 E ELVA ST
Second Line	:
City	:	IDAHO FALLS
State	:	ID
Zip	:	83401-2801
Country	:	US
Telephone Number	:	208-523-4795
Fax Number	:	208-522-9175

Authorized Official
Title or Position	:	CFO
Name	:	MS. RAYE NAE NYLANDER
Credential	:
Telephone Number	:	605-362-3100

Provider Enumeration Date	:	10/25/2005
Last Update Date	:	10/25/2021

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Directions to “THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY ” Practice Location

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