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General NPI Number Information
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NPI Number | 1538527106
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Entity Type | Organization
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Legal Business Name | AVERA MCKENNAN
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Dates
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Enumeration Date | 02/10/2016
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Last Update Date | 10/04/2023
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Provider Practice Location Address
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Address Line | 310 W SD HIGHWAY 46
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City | WAGNER
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State | SD
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Zip | 57380-9304
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Country | US
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Telephone | 605-384-4980
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Fax | 605-384-4990
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Provider Business Mailing Address
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Address Line | PO BOX 5045 PFS PROV ENRLLMT
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City | SIOUX FALLS
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State | SD
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Zip | 57117-5045
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Country | US
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Telephone | 605-322-6404
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | RONALD JOSEPH PLACE
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Credential | MD
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Telephone | 605-322-7903
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QE0700X
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Taxonomy Name | End-Stage Renal Disease (ESRD) Treatment Clinic/Center
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License Number | 10563
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License Number State | SD
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