Healthcare Provider Details

I. General information

NPI: 1942205646
Provider Name (Legal Business Name): AVERA QUEEN OF PEACE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 1ST ST NE
WESSINGTON SPRINGS SD
57382-2134
US

IV. Provider business mailing address

525 N FOSTER ST
MITCHELL SD
57301-2966
US

V. Phone/Fax

Practice location:
  • Phone: 605-539-1021
  • Fax: 605-539-4580
Mailing address:
  • Phone: 605-995-2000
  • Fax: 605-995-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number48209
License Number StateSD

VIII. Authorized Official

Name: DOUGLAS EKEREN
Title or Position: PRESIDENT/CEO
Credential:
Phone: 605-668-8322