Provider Demographics
NPI:1972082683
Name:AVERA ST. MARY'S
Entity Type:Organization
Organization Name:AVERA ST. MARY'S
Other - Org Name:AVERA THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MIKEL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-224-3144
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:CBO PALM PLACE PROVENRLMT
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:650-322-6428
Mailing Address - Fax:
Practice Address - Street 1:1211 E WELLS AVE
Practice Address - Street 2:
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501-3962
Practice Address - Country:US
Practice Address - Phone:605-224-3100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty