Healthcare Provider Details

I. General information

NPI: 1669622031
Provider Name (Legal Business Name): AVERA MARSHALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

IV. Provider business mailing address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

V. Phone/Fax

Practice location:
  • Phone: 507-532-9661
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number338730
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number338730
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE STREIER
Title or Position: CEO
Credential:
Phone: 507-537-9160