1053301457 NPI number — THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Table of content: (NPI 1053301457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053301457 NPI number — THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053301457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
405 WEST 7TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILVERTON
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83867-0358
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-556-1147
Provider Business Practice Location Address Fax Number:
208-753-6411
Provider Enumeration Date:
10/26/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NYLANDER
Authorized Official First Name:
RAYE NAE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
605-362-3100

Provider Taxonomy Codes

  • Taxonomy code: 332BP3500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332BN1400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 806366900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0003721 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000010012644 . This is a "REGENCE BLUE SHIELD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 805819800 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01545 . This is a "BLUE CROSS IDAHO" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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