1760423057 NPI number — AVERA ST LUKES

Table of content: (NPI 1760423057)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760423057 NPI number — AVERA ST LUKES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA ST LUKES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
AVERA CLINIC OF ELLENDALE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760423057
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 86370
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57118-6370
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-4933
Provider Business Mailing Address Fax Number:
605-504-9489

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLENDALE
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58436
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-349-3666
Provider Business Practice Location Address Fax Number:
701-349-4945
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BJERKNES
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
605-622-5125

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: N70860 . This is a "MEDICARE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 5301013 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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