Healthcare Provider Details

I. General information

NPI: 1912011867
Provider Name (Legal Business Name): AVERA ST LUKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 10/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S STATE ST
ABERDEEN SD
57401-4527
US

IV. Provider business mailing address

305 S STATE ST
ABERDEEN SD
57401-4527
US

V. Phone/Fax

Practice location:
  • Phone: 605-622-5000
  • Fax: 605-622-5255
Mailing address:
  • Phone: 605-622-5000
  • Fax: 605-622-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number10525
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number10525
License Number StateSD
# 3
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number10525
License Number StateSD

VIII. Authorized Official

Name: RONALD L JACOBSON
Title or Position: CEO
Credential:
Phone: 605-622-5125