Provider Demographics
NPI:1851336887
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA WINNER MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/SVP
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7818
Mailing Address - Street 1:1436 E 10TH ST
Mailing Address - Street 2:STE #2
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-2875
Mailing Address - Country:US
Mailing Address - Phone:605-842-2443
Mailing Address - Fax:605-842-1650
Practice Address - Street 1:1436 E 10TH ST
Practice Address - Street 2:
Practice Address - City:WINNER
Practice Address - State:SD
Practice Address - Zip Code:57580-2818
Practice Address - Country:US
Practice Address - Phone:605-842-2443
Practice Address - Fax:605-842-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD3344261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center