Provider Demographics
NPI:1891718136
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA MCKENNAN REGIONAL LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
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:605-322-7916
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:ATTN: P.F.S.
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-7187
Mailing Address - Fax:605-322-7183
Practice Address - Street 1:1301 S CLIFF AVE
Practice Address - Street 2:REGIONAL LAB
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-1005
Practice Address - Country:US
Practice Address - Phone:605-322-7187
Practice Address - Fax:605-322-7183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD43D0658878291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4995742OtherBLUE CROSS OF SD
SD604999OtherARAZ
SD5580610Medicaid
SD1034593OtherPREFERRED ONE
MN165L6AVOtherBLUE CROSS OF MINNESOTA
SDF230764OtherMIDLANDS CHOICE
IA0569285Medicaid
SDF230764OtherMIDLANDS CHOICE
SD4995742OtherBLUE CROSS OF SD