Healthcare Provider Details

I. General information

NPI: 1851336887
Provider Name (Legal Business Name): AVERA MCKENNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1436 E 10TH ST
WINNER SD
57580-2818
US

IV. Provider business mailing address

1436 E 10TH ST STE #2
WINNER SD
57580-2875
US

V. Phone/Fax

Practice location:
  • Phone: 605-842-2443
  • Fax: 605-842-1650
Mailing address:
  • Phone: 605-842-2443
  • Fax: 605-842-1650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3344
License Number StateSD

VIII. Authorized Official

Name: JULIE NORTON
Title or Position: CFO/SVP
Credential:
Phone: 605-322-7818