1588730600 NPI number — AVERA HOME MEDICAL EQUIPMENT, LLC

Table of content: (NPI 1588730600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588730600 NPI number — AVERA HOME MEDICAL EQUIPMENT, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA HOME MEDICAL EQUIPMENT, LLC
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:
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:
1588730600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 E 21ST ST
Provider Second Line Business Mailing Address:
PO BOX 5045
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-1872
Provider Business Mailing Address Fax Number:
605-322-1892

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 E SPRUCE ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MITCHELL
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57301-4866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-996-1394
Provider Business Practice Location Address Fax Number:
605-996-1432
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DIELEMAN
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT/CEO
Authorized Official Telephone Number:
605-322-1872

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  17006EST001 , 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: 9162064 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".




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