Provider Demographics
NPI:1760681175
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:MOODY COUNTY PUBLIC HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:BARB
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-997-3779
Mailing Address - Street 1:309 N PRAIRIE ST
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028-1253
Mailing Address - Country:US
Mailing Address - Phone:605-997-3779
Mailing Address - Fax:605-997-3273
Practice Address - Street 1:309 N PRAIRIE ST
Practice Address - Street 2:
Practice Address - City:FLANDREAU
Practice Address - State:SD
Practice Address - Zip Code:57028-1253
Practice Address - Country:US
Practice Address - Phone:605-997-3779
Practice Address - Fax:605-997-3273
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5102100Medicaid
SD5102100Medicaid