1700429610 NPI number — AVERA GRANITE FALLS

Table of content: JERRY S. NNANABU M.D. (NPI 1902287246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700429610 NPI number — AVERA GRANITE FALLS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA GRANITE FALLS
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 GRANITE FALLS HEALTH CENTER
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:
1700429610
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 S BRUCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARSHALL
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56258-1934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
345 10TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANITE FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56241-1442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
320-564-3111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2019

Additional Information

Authorized Official

Authorized Official Last Name:
STREIER
Authorized Official First Name:
DEBRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
507-537-9160

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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