Healthcare Provider Details

I. General information

NPI: 1851848444
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 S MARION ROAD STE 125
SIOUX FALLS SD
57106-3645
US

IV. Provider business mailing address

2100 S MARION ROAD STE 125
SIOUX FALLS SD
57106-3645
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-3790
  • Fax:
Mailing address:
  • Phone: 605-322-3790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DAVID FLICEK
Title or Position: CEO/PRESIDENT
Credential:
Phone: 605-322-8000