Healthcare Provider Details

I. General information

NPI: 1841511904
Provider Name (Legal Business Name): AVERA ST MARYS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2010
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E SIOUX AVE
PIERRE SD
57501
US

IV. Provider business mailing address

PO BOX 5045 CBO PALM PLACE PRVENROLLMT
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-3100
  • Fax: 605-224-8339
Mailing address:
  • Phone: 605-322-6428
  • Fax: 605-322-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number10662
License Number StateSD

VIII. Authorized Official

Name: MIKEL HOLLAND
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-224-3144