Healthcare Provider Details

I. General information

NPI: 1083859532
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 04/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LN
PIERRE SD
57501-3391
US

IV. Provider business mailing address

100 MAC LN
PIERRE SD
57501-3391
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-5901
  • Fax: 605-945-3244
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number11146
License Number StateSD

VIII. Authorized Official

Name: JULIE N NORTON
Title or Position: VP FINANCE
Credential:
Phone: 605-322-6375