Healthcare Provider Details

I. General information

NPI: 1033114731
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S OHLMAN ST
MITCHELL SD
57301-3109
US

IV. Provider business mailing address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

V. Phone/Fax

Practice location:
  • Phone: 605-996-7701
  • Fax:
Mailing address:
  • Phone: 605-995-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number10652
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
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: DOUGLAS EKEREN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 605-668-8322