Healthcare Provider Details

I. General information

NPI: 1326495409
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2016
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 PARK AVE
GREGORY SD
57533-1302
US

IV. Provider business mailing address

400 PARK AVE
GREGORY SD
57533-1302
US

V. Phone/Fax

Practice location:
  • Phone: 605-835-5190
  • Fax: 605-835-5479
Mailing address:
  • Phone: 605-835-5190
  • Fax: 605-835-5479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0345
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name: JULIE NORTON
Title or Position: CFO/SVP
Credential:
Phone: 605-322-7818