Provider Demographics
NPI:1467474239
Name:AVERA AT HOME
Entity Type:Organization
Organization Name:AVERA AT HOME
Other - Org Name:AVERA@HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
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:605-322-1872
Mailing Address - Fax:605-322-1892
Practice Address - Street 1:4509 PRINCE OF PEACE PL
Practice Address - Street 2:HOSPICE UNIT
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-5830
Practice Address - Country:US
Practice Address - Phone:605-322-5490
Practice Address - Fax:605-322-3179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0929828Medicaid
MN1484AMCOtherBLUE CROSS OF MINNESOTA
IA0929828Medicaid
SD0154040Medicaid
SD81503OtherBLUE CROSS OF SD