Healthcare Provider Details

I. General information

NPI: 1386305829
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 03/16/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

IV. Provider business mailing address

PO BOX 5045 ATTN PRVENROLMT PALM PLACE BLDG
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-2000
  • Fax:
Mailing address:
  • Phone: 605-322-6428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number State

VIII. Authorized Official

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