1851547798 NPI number — AVERA ST. LUKE'S

Table of content: ANNABELLE CELLA M.ED., BCBA, LBA (NPI 1366017766)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851547798 NPI number — AVERA ST. LUKE'S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA ST. LUKE'S
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:
1851547798
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1460
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABERDEEN
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57402-1460
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-725-5030
Provider Business Mailing Address Fax Number:
605-725-5028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 S LLOYD ST
Provider Second Line Business Practice Location Address:
SUITE W230
Provider Business Practice Location Address City Name:
ABERDEEN
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57401-4552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-725-5030
Provider Business Practice Location Address Fax Number:
605-725-5028
Provider Enumeration Date:
08/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FORKEL
Authorized Official First Name:
TODD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT & CEO
Authorized Official Telephone Number:
605-622-5125

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  10525 , 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: 14893 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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