Provider Demographics
NPI:1962484022
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity Type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:GOOD SAMARITAN SOCIETY - DAYTONA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDEN HULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-362-3100
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 1:325 S SEGRAVE ST
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4220
Practice Address - Country:US
Practice Address - Phone:386-253-6791
Practice Address - Fax:386-258-3842
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-15
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL141221300OtherMEDICAID ALF OSS
FL7100409OtherEVERCARE
FL675714601Medicaid
FL020439100Medicaid
FLK2SOtherBLUE CROSS BLUE SHIELD
FL141221300OtherMEDICAID ALF OSS
FL675714601Medicaid