Healthcare Provider Details

I. General information

NPI: 1467695767
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 01/08/2021
Certification Date: 01/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 23RD ST SUITE 330
SIOUX FALLS SD
57105-2113
US

IV. Provider business mailing address

PO BOX 5045 ATTN: PT FINAN SERVICES
SIOUX FALLS SD
57117-5045
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-7465
  • Fax: 605-322-1789
Mailing address:
  • Phone: 605-322-6400
  • Fax: 605-322-6499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number10563
License Number StateSD

VIII. Authorized Official

Name: DAVID FLICEK
Title or Position: PRESIDENT/CEO
Credential:
Phone: 605-322-7916