Provider Demographics
NPI:1952330706
Name:AVERA MCKENNAN
Entity Type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:AVERA ROSEBUD COUNTRY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FLICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-7915
Mailing Address - Street 1:PO BOX 408
Mailing Address - Street 2:400 PARK AVENUE
Mailing Address - City:GREGORY
Mailing Address - State:SD
Mailing Address - Zip Code:57533-0408
Mailing Address - Country:US
Mailing Address - Phone:605-835-8296
Mailing Address - Fax:605-835-9422
Practice Address - Street 1:126 S LOGAN AVE
Practice Address - Street 2:
Practice Address - City:GREGORY
Practice Address - State:SD
Practice Address - Zip Code:57533-1612
Practice Address - Country:US
Practice Address - Phone:605-835-8296
Practice Address - Fax:605-835-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD10625314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0150070Medicaid
SD0150070Medicaid