Provider Demographics
NPI:1639274731
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:ST. VINCENT'S - A PROSPERA COMMUNITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEN HULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-5510
Mailing Address - Street 1:1021 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3109
Mailing Address - Country:US
Mailing Address - Phone:701-233-6888
Mailing Address - Fax:701-223-3127
Practice Address - Street 1:1021 N 26TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3109
Practice Address - Country:US
Practice Address - Phone:701-233-6888
Practice Address - Fax:701-223-3127
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-13
Last Update Date:2021-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1005B314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1005BOtherSTATE
ND1469240Medicaid
1347OtherBCBS
ND355060Medicare Oscar/Certification