Basic Information
| Provider Information | |||||||||
| NPI: | 1861473852 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GOOD SAMARITAN SOCIETY - MOHALL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5038 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053623100 | ||||||||
| FaxNumber: | 6053623265 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 MAIN ST E | ||||||||
| Address2: | |||||||||
| City: | MOHALL | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587614100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017566831 | ||||||||
| FaxNumber: | 7017566357 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 11/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NYLANDER | ||||||||
| AuthorizedOfficialFirstName: | RAYE NAE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053623100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BN1400X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Nursing Facility Supplies | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 30173 | 05 | ND | MEDICAID | 4721 | 01 | ND | BLUE CROSS BLUE SHIELD | OTHER | 30741 | 05 | ND | MEDICAID |