Healthcare Provider Details

I. General information

NPI: 1760681175
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2007
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N PRAIRIE ST
FLANDREAU SD
57028-1253
US

IV. Provider business mailing address

309 N PRAIRIE ST
FLANDREAU SD
57028-1253
US

V. Phone/Fax

Practice location:
  • Phone: 605-997-3779
  • Fax: 605-997-3273
Mailing address:
  • Phone: 605-997-3779
  • Fax: 605-997-3273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: BARB J. SHEA
Title or Position: BUSINESS OFFICE ASSISTANT
Credential:
Phone: 605-997-3779