Basic Information
| Provider Information | |||||||||
| NPI: | 1841520723 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GOOD SAMARITAN SOCIETY - GRAND ISLAND VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 W 57TH ST | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571082239 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4075 TIMBERLINE ST | ||||||||
| Address2: | |||||||||
| City: | GRAND ISLAND | ||||||||
| State: | NE | ||||||||
| PostalCode: | 688036553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3083843535 | ||||||||
| FaxNumber: | 3086750980 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2009 | ||||||||
| LastUpdateDate: | 11/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NYLANDER | ||||||||
| AuthorizedOfficialFirstName: | RAYE NAE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT, CFO | ||||||||
| AuthorizedOfficialTelephone: | 6053623100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE EVANGELICAL LUTHERAN GOOD SAMARITAN SOCIETY | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.