1841511904 NPI number — AVERA ST MARYS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841511904 NPI number — AVERA ST MARYS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA ST MARYS
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:
MARYHOUSE ADULT DAY CARE
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:
1841511904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5045
Provider Second Line Business Mailing Address:
CBO PALM PLACE PRVENROLLMT
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57117-5045
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-6428
Provider Business Mailing Address Fax Number:
605-322-6499

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 E SIOUX AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIERRE
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-224-3100
Provider Business Practice Location Address Fax Number:
605-224-8339
Provider Enumeration Date:
06/11/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOLLAND
Authorized Official First Name:
MIKEL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
605-224-3144

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  10662 , 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)