Healthcare Provider Details

I. General information

NPI: 1215932918
Provider Name (Legal Business Name): AVERA AT HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 E 5TH AVE
MITCHELL SD
57301-2917
US

IV. Provider business mailing address

PO BOX 5045
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-2268
  • Fax: 605-995-5624
Mailing address:
  • Phone: 605-322-1872
  • Fax: 605-322-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MS. SANDRA D DIELEMAN
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-322-3984