Healthcare Provider Details

I. General information

NPI: 1346494697
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N SPLITROCK BLVD
BRANDON SD
57005-1529
US

IV. Provider business mailing address

PO BOX 5045 ATTN: PROVIDER ENROLLMENT PT FINANCIAL SERVICES
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-582-3908
  • Fax: 605-582-3349
Mailing address:
  • Phone: 605-322-6428
  • Fax: 605-322-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number10563
License Number StateSD

VIII. Authorized Official

Name: RONALD JOSEPH PLACE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 605-322-7903