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General NPI Number Information
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NPI Number | 1932105046
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Entity Type | Organization
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Legal Business Name | AVERA QUEEN OF PEACE
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Dates
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Enumeration Date | 06/23/2005
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Last Update Date | 08/20/2020
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Provider Practice Location Address
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Address Line | 265 MAIN STREET
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City | CORSICA
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State | SD
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Zip | 57328
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Country | US
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Telephone | 605-946-5411
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Fax | 605-946-5206
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Provider Business Mailing Address
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Address Line | 525 N FOSTER ST
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City | MITCHELL
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State | SD
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Zip | 57301-2966
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Country | US
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Telephone | 605-995-2000
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Fax | 605-995-2441
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DOUGLAS EKEREN
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Credential |
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Telephone | 605-668-8322
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number | N/A
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License Number State | SD
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