Healthcare Provider Details

I. General information

NPI: 1508177890
Provider Name (Legal Business Name): AVERA MARSHALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 3RD AVE
MOUNTAIN LAKE MN
56159-1587
US

IV. Provider business mailing address

1040 3RD AVE
MOUNTAIN LAKE MN
56159-1587
US

V. Phone/Fax

Practice location:
  • Phone: 507-427-2345
  • Fax:
Mailing address:
  • Phone: 507-427-2345
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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