Provider Demographics
NPI:1093812471
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MCKENNAN DBA AVERA FULDA CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CFO/SVP
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7818
Mailing Address - Street 1:201 N ST. PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:FULDA
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2343
Mailing Address - Country:US
Mailing Address - Phone:507-372-2921
Mailing Address - Fax:507-372-5789
Practice Address - Street 1:1216 RYANS RD
Practice Address - Street 2:SUITE 1
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1722
Practice Address - Country:US
Practice Address - Phone:507-372-2921
Practice Address - Fax:507-372-5789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center