Provider Demographics
NPI:1235110016
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:CAPESIDE COVE GOOD SAMARITAN CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAYE NAE
Authorized Official - Middle Name:
Authorized Official - Last Name:NYLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3100
Mailing Address - Street 1:PO BOX 5038
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5038
Mailing Address - Country:US
Mailing Address - Phone:605-362-3100
Mailing Address - Fax:605-362-3265
Practice Address - Street 1:23926 4TH AVE S
Practice Address - Street 2:
Practice Address - City:SIREN
Practice Address - State:WI
Practice Address - Zip Code:54872-8334
Practice Address - Country:US
Practice Address - Phone:715-349-2292
Practice Address - Fax:715-349-7218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20158900Medicaid
WI1026758OtherPREFERRED ONE - INPATIENT
WI7122742OtherMEDICA
WI9840CAOtherBLUE CROSS BLUE SHIELD
WI1014259OtherPREFERRED ONE - THERAPY
WI9840CAOtherBLUE CROSS BLUE SHIELD
WI20158900Medicaid