Provider Demographics
NPI:1124023825
Name:AVERA AT HOME
Entity Type:Organization
Organization Name:AVERA AT HOME
Other - Org Name:AVERA@HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIELEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-3984
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:606-332-1872
Mailing Address - Fax:605-322-1892
Practice Address - Street 1:1115 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2917
Practice Address - Country:US
Practice Address - Phone:605-995-2268
Practice Address - Fax:605-995-5624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-17
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDN/A315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD431507Medicare Oscar/Certification
SD43-1507Medicare ID - Type Unspecified