Provider Demographics
NPI:1184008047
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY - LUTHER MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:GRANT
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3100
Mailing Address - Street 1:4800 W 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2239
Mailing Address - Country:US
Mailing Address - Phone:605-362-3100
Mailing Address - Fax:
Practice Address - Street 1:1500 W 38TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5563
Practice Address - Country:US
Practice Address - Phone:605-336-1997
Practice Address - Fax:605-336-8703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
S109080OtherMEDICARE PART B