Provider Demographics
NPI:1710082904
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:MILLER POINTE - 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 1:201 14TH ST NW
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-2063
Mailing Address - Country:US
Mailing Address - Phone:701-663-4274
Mailing Address - Fax:701-663-0359
Practice Address - Street 1:3500 21ST ST SE
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-1341
Practice Address - Country:US
Practice Address - Phone:701-663-4274
Practice Address - Fax:701-663-0359
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
ND1090314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1469241Medicaid
8495OtherBCBS
ND1090OtherSTATE
ND355106Medicare Oscar/Certification