Provider Demographics
NPI:1356799316
Name:AVERA HOME MEDICAL EQUIPMENT, LLC
Entity type:Organization
Organization Name:AVERA HOME MEDICAL EQUIPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIELEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-3984
Mailing Address - Street 1:525 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2966
Mailing Address - Country:US
Mailing Address - Phone:605-995-2460
Mailing Address - Fax:605-322-1892
Practice Address - Street 1:525 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2966
Practice Address - Country:US
Practice Address - Phone:605-995-2460
Practice Address - Fax:605-322-1892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDUNPD3R332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies