Healthcare Provider Details

I. General information

NPI: 1912958877
Provider Name (Legal Business Name): AVERA AT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S. LLOYD STREET STE 210 W,
ABERDEEN SD
57401-4527
US

IV. Provider business mailing address

PO BOX 5045
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-622-5200
  • Fax: 605-622-5201
Mailing address:
  • Phone: 605-322-1872
  • Fax: 605-322-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number4069A
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: SANDRA D DIELEMAN
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-322-3984