MEDICARE: AVERA QUEEN OF PEACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies	10652	SD
2	332BP3500X	Parenteral & Enteral Nutrition Supplies (DME)	N/A	SD

General Provider Information

NPI Number	:	1033114731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVERA QUEEN OF PEACE

Provider Business Mailing Address
First Line	:	525 N FOSTER ST
Second Line	:
City	:	MITCHELL
State	:	SD
Zip	:	57301-2966
Country	:	US
Telephone Number	:	605-995-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 S OHLMAN ST
Second Line	:
City	:	MITCHELL
State	:	SD
Zip	:	57301-3109
Country	:	US
Telephone Number	:	605-996-7701
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	DOUGLAS EKEREN
Credential	:
Telephone Number	:	605-668-8322

Provider Enumeration Date	:	06/17/2005
Last Update Date	:	08/20/2020

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Directions to “AVERA QUEEN OF PEACE ” Practice Location

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