Healthcare Provider Details

I. General information

NPI: 1417378555
Provider Name (Legal Business Name): AVERA MARSHALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2013
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 10TH ST
WORTHINGTON MN
56187-2767
US

IV. Provider business mailing address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

V. Phone/Fax

Practice location:
  • Phone: 507-376-5535
  • Fax: 507-376-4805
Mailing address:
  • Phone: 507-532-9661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

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