1770791402 NPI number — AVERA MCKENNAN

Table of content: (NPI 1770791402)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770791402 NPI number — AVERA MCKENNAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA MCKENNAN
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 BUTTE HOME HEALTH BRANCH
Provider Other Organization Name Type Code:
5
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:
1770791402
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 408
Provider Second Line Business Mailing Address:
GREGORY HOMECARE DEPT
Provider Business Mailing Address City Name:
GREGORY
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57533-0408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-835-8394
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
730 WILSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUTTE
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68722-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-835-8394
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NORTON
Authorized Official First Name:
JULIE
Authorized Official Middle Name:
Authorized Official Title or Position:
VP/CFO
Authorized Official Telephone Number:
605-322-6375

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  10563 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 9550490 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9556080 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0171450 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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