Provider Demographics
NPI:1932319589
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA FLANDREAU HOME HEALTH BRANCH
Other - Org Type:Other Name
Authorized Official - Title/Position:VP/CFO
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:605-322-6375
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:2007-05-23
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10563251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD437023Medicare Oscar/Certification