Provider Demographics
NPI:1144225129
Name:AVERA QUEEN OF PEACE
Entity Type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:AVERA BRADY HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EKEREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-668-8322
Mailing Address - Street 1:525 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2966
Mailing Address - Country:US
Mailing Address - Phone:605-995-5200
Mailing Address - Fax:605-995-2441
Practice Address - Street 1:500 S OHLMAN ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-3109
Practice Address - Country:US
Practice Address - Phone:605-996-7701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA QUEEN OF PEACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-16
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10652314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0151182Medicaid
SD435061Medicare Oscar/Certification