1962484022 NPI number — THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY

Table of content: (NPI 1962484022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962484022 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:
1962484022
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:
325 S SEGRAVE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32114-4220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-253-6791
Provider Business Practice Location Address Fax Number:
386-258-3842
Provider Enumeration Date:
11/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
VANDEN HULL
Authorized Official First Name:
ERIC
Authorized Official Middle Name:
Authorized Official Title or Position:
VP, FINANCE
Authorized Official Telephone Number:
605-362-3100

Provider Taxonomy Codes

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

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

  • Identifier: 141221300 . This is a "MEDICAID ALF OSS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 7100409 . This is a "EVERCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 675714601 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 020439100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: K2S . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 020439100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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