1144206020 NPI number — AVERA ST. LUKES

Table of content: (NPI 1144206020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144206020 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:
Provider Other Organization Name Type Code:
6
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:
1144206020
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 40
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUREKA
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57437-0040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-284-2145
Provider Business Mailing Address Fax Number:
605-284-2011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
202 J AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUREKA
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57437-2225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-284-2145
Provider Business Practice Location Address Fax Number:
605-284-2011
Provider Enumeration Date:
12/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MOELLER
Authorized Official First Name:
TESS
Authorized Official Middle Name:
Authorized Official Title or Position:
VP
Authorized Official Telephone Number:
605-622-2807

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  10618 , 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: 0150060 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9572202 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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