Provider Demographics
NPI:1124547146
Name:GOOD SAMARITAN SUPPORTED LIVING, LLC
Entity Type:Organization
Organization Name:GOOD SAMARITAN SUPPORTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RN MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA THERESA
Authorized Official - Middle Name:YEBRA
Authorized Official - Last Name:VILLANUEVA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:614-893-0579
Mailing Address - Street 1:616 MAWYER DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43085-5403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:616 MAWYER DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43085-5403
Practice Address - Country:US
Practice Address - Phone:614-893-0579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH318641163W00000X
163W00000X, 164W00000X, 3747A0650X, 3747P1801X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty