Healthcare Provider Details

I. General information

NPI: 1689051682
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 S OHLMAN ST
MITCHELL SD
57301-3106
US

IV. Provider business mailing address

409 S OHLMAN ST
MITCHELL SD
57301-3106
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-4552
  • Fax: 605-996-0577
Mailing address:
  • Phone: 605-996-4552
  • Fax: 605-996-0577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DOUGLAS EKEREN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 605-668-8322