Healthcare Provider Details

I. General information

NPI: 1356799316
Provider Name (Legal Business Name): AVERA HOME MEDICAL EQUIPMENT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

IV. Provider business mailing address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-2460
  • Fax: 605-322-1892
Mailing address:
  • Phone: 605-995-2460
  • Fax: 605-322-1892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberUNPD3R
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name: SANDRA D DIELEMAN
Title or Position: MEMBER REPRESENTATIVE
Credential:
Phone: 605-322-3984