Provider Demographics
NPI:1659595841
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:FLORIDA LUTHERAN RETIREMENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, 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 1:4800 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:605-362-3100
Mailing Address - Fax:
Practice Address - Street 1:436 N MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-3634
Practice Address - Country:US
Practice Address - Phone:386-738-0212
Practice Address - Fax:386-738-5197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6757146-00Medicaid