Healthcare Provider Details

I. General information

NPI: 1093759177
Provider Name (Legal Business Name): AVERA ST. LUKE'S
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S LLOYD ST SUITE E202
ABERDEEN SD
57401-4552
US

IV. Provider business mailing address

PO BOX 1460
ABERDEEN SD
57402-1460
US

V. Phone/Fax

Practice location:
  • Phone: 605-622-2898
  • Fax: 605-622-2897
Mailing address:
  • Phone: 605-622-2898
  • Fax: 605-622-2897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number10525
License Number StateSD

VIII. Authorized Official

Name: TESS MOELLER
Title or Position: VP
Credential:
Phone: 605-622-2807