Provider Demographics
NPI:1467786640
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA PRINCE OF PEACE OUTPATIENT THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:FLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7915
Mailing Address - Street 1:800 E 21ST ST
Mailing Address - Street 2:PO BOX 5045, PROV ENROLLMENT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-1016
Mailing Address - Country:US
Mailing Address - Phone:605-322-6400
Mailing Address - Fax:605-322-6499
Practice Address - Street 1:4513 S PRINCE OF PEACE PL STE 1
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-5830
Practice Address - Country:US
Practice Address - Phone:605-322-5618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-22
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025846700 (OT GRP)Medicaid
NE10025846600 (PT )Medicaid
IA1467786640Medicaid
MN1467786640Medicaid
SD9290262OtherDAKOTACARE
IA1467786640Medicaid