Provider Demographics
NPI:1407890437
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 HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSON
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:
Mailing Address - Fax:
Practice Address - Street 1:1065 RUTH ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-4454
Practice Address - Country:US
Practice Address - Phone:928-443-9331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-16
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD037238Medicare Oscar/Certification