Provider Demographics
NPI:1326238874
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY-PRESCOTT HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:TRIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3900
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:
Mailing Address - Fax:
Practice Address - Street 1:1065 RUTH ST
Practice Address - Street 2:SUITE 108-109
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301
Practice Address - Country:US
Practice Address - Phone:928-778-5655
Practice Address - Fax:928-445-2497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
031584Medicare Oscar/Certification