Provider Demographics
NPI:1811987381
Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Entity type:Organization
Organization Name:THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY
Other - Org Name:<UNAVAIL>
Other - Org Type:
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: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 1:3815 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2207
Practice Address - Country:US
Practice Address - Phone:763-588-4635
Practice Address - Fax:763-588-9405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-26
Last Update Date:2007-07-19
Deactivation Date:2006-10-25
Deactivation Code:
Reactivation Date:2007-07-19
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7110090OtherMEDICA CHOICE
MN7111785OtherEVERCARE (MEDICA)
MN5A13CRMedicaidASSISTED LIVING
MNNH0014OtherUCARE OF MN
MN1026653OtherPREFERRED ONE
MN245152Medicare ID - Type Unspecified