Healthcare Provider Details

I. General information

NPI: 1376519116
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 05/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E FIGZEL CT SUITE 100
TEA SD
57064-2276
US

IV. Provider business mailing address

PO BOX 86430
SIOUX FALLS SD
57118-6430
US

V. Phone/Fax

Practice location:
  • Phone: 605-368-9899
  • Fax: 605-368-5089
Mailing address:
  • Phone: 605-322-4900
  • Fax: 605-322-4910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIE N NORTON
Title or Position: SR VICE PRESIDENT OF FINANCE
Credential:
Phone: 605-322-6375