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General NPI Number Information
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NPI Number | 1770680787
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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 | 09/20/2006
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Last Update Date | 09/10/2020
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Provider Practice Location Address
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Address Line | 409 4TH ST
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City | WILMOT
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State | SD
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Zip | 57279-2214
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Country | US
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Telephone | 605-938-4351
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Fax | 605-938-4351
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Provider Business Mailing Address
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Address Line | 409 4TH ST
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City | WILMOT
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State | SD
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Zip | 57279-2214
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Country | US
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Telephone | 605-938-4351
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Fax | 605-938-4351
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DAVID FLICEK
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Credential |
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Telephone | 605-322-7916
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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