Provider Demographics
NPI:1114407574
Name:GOOD SAMARITAN VILLAGE LLLP
Entity Type:Organization
Organization Name:GOOD SAMARITAN VILLAGE LLLP
Other - Org Name:GOOD SAMARITAN VILLAGE LLLP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:APPIAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-558-4189
Mailing Address - Street 1:26442 WHIRLAWAY TER
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-1552
Mailing Address - Country:US
Mailing Address - Phone:203-558-4189
Mailing Address - Fax:
Practice Address - Street 1:26442 WHIRLAWAY TER
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-1552
Practice Address - Country:US
Practice Address - Phone:860-794-6457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL714547261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL714547Medicaid