Provider Demographics
NPI:1144534702
Name:AVERA HOME MEDICAL EQUIPMENT OF SPENCER HOSPITAL LLC
Entity type:Organization
Organization Name:AVERA HOME MEDICAL EQUIPMENT OF SPENCER HOSPITAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIELEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-1872
Mailing Address - Street 1:116 E 11TH ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4300
Mailing Address - Country:US
Mailing Address - Phone:712-580-3923
Mailing Address - Fax:712-580-3921
Practice Address - Street 1:116 E 11TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4300
Practice Address - Country:US
Practice Address - Phone:712-580-3923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1-21-008187332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
6453370001Medicare NSC