Healthcare Provider Details

I. General information

NPI: 1811091473
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 04/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARK AVE
GREGORY SD
57533-1302
US

IV. Provider business mailing address

PO BOX 5045 ATTN: P.F.S. PROV ENROLLMENT
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-835-8394
  • Fax: 605-835-9422
Mailing address:
  • Phone: 605-322-6400
  • Fax: 605-322-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9550490
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 2
Identifier0171450
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer
# 3
Identifier9556080
Identifier TypeMEDICAID
Identifier StateSD
Identifier Issuer

VIII. Authorized Official

Name: JULIE NORTON
Title or Position: VP/CFO
Credential:
Phone: 605-322-6375