Provider Demographics
NPI:1346494697
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MCKENNAN OUTPATIENT THERAPY SERVICES - BRANDON
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:PO BOX 5045
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT PT FINANCIAL SERVICES
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-6428
Mailing Address - Fax:605-322-6499
Practice Address - Street 1:103 N SPLITROCK BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-1529
Practice Address - Country:US
Practice Address - Phone:605-582-3908
Practice Address - Fax:605-582-3349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-13
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1346494697Medicare PIN
SDS30016Medicare PIN