Healthcare Provider Details

I. General information

NPI: 1710316252
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4210 W 53RD ST
SIOUX FALLS SD
57106-4257
US

IV. Provider business mailing address

PO BOX 5045 ATTN: P.F.S. PROV ENROLLMENT
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-1490
  • Fax:
Mailing address:
  • Phone: 605-322-6400
  • Fax: 605-322-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number10563
License Number StateSD

VII. Legacy identifiers

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

VIII. Authorized Official

Name: RONALD JOSEPH PLACE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 605-322-7903