Provider Demographics
NPI:1588645600
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:WILLOW WIND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
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 1:3191 ASTER DR
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-3743
Practice Address - Country:US
Practice Address - Phone:928-443-9999
Practice Address - Fax:928-778-5251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ487125Medicaid