Provider Demographics
NPI:1629372719
Name:AVERA AT HOME
Entity Type:Organization
Organization Name:AVERA AT HOME
Other - Org Name:AVERA@HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
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 186
Mailing Address - Street 2:
Mailing Address - City:CREIGHTON
Mailing Address - State:NE
Mailing Address - Zip Code:68729-0186
Mailing Address - Country:US
Mailing Address - Phone:402-358-5755
Mailing Address - Fax:402-358-5769
Practice Address - Street 1:1503 MAIN ST
Practice Address - Street 2:
Practice Address - City:CREIGHTON
Practice Address - State:NE
Practice Address - Zip Code:68729-3019
Practice Address - Country:US
Practice Address - Phone:402-358-5755
Practice Address - Fax:402-358-5769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE201404251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE287039Medicare Oscar/Certification