Healthcare Provider Details

I. General information

NPI: 1023413093
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GRASSLAND DR STE 102
MITCHELL SD
57301-6205
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 605-995-6730
  • Fax:
Mailing address:
  • Phone: 605-322-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number10563
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

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