Healthcare Provider Details

I. General information

NPI: 1851396550
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

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: 605-995-5672
Mailing address:
  • Phone: 605-995-2460
  • Fax: 605-995-5672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number100-1023
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number100-1023
License Number StateSD

VIII. Authorized Official

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