Provider Demographics
NPI:1225201205
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MCKENNAN BEHAVIORAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:605-322-7903
Mailing Address - Street 1:4400 W 69TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-8170
Mailing Address - Country:US
Mailing Address - Phone:605-322-4000
Mailing Address - Fax:605-322-4009
Practice Address - Street 1:4400 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8170
Practice Address - Country:US
Practice Address - Phone:605-322-4000
Practice Address - Fax:605-322-4009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA MCKENNAN HOSPITAL AND UNIVERSITY HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-10
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN475747502Medicaid