1891738365 NPI number — AVERA HOLY FAMILY

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 1891738365 NPI number — AVERA HOLY FAMILY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AVERA HOLY FAMILY
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:
1891738365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
826 N 8TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ESTHERVILLE
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51334-1528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-362-2631
Provider Business Mailing Address Fax Number:
712-362-2636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
826 N 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ESTHERVILLE
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51334-1528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-362-2631
Provider Business Practice Location Address Fax Number:
712-362-2636
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HERZBERG
Authorized Official First Name:
DEB
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
712-362-6160

Provider Taxonomy Codes

  • Taxonomy code: 282NC0060X , with the licence number:  320014H , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0655845 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 66002 . This is a "WELLMARK IA SWING BED" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".




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