Provider Demographics
NPI:1538234257
Name:AVERA MCKENNAN
Entity type:Organization
Organization Name:AVERA MCKENNAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-997-2471
Mailing Address - Street 1:212 N PRAIRIE STREET
Mailing Address - Street 2:
Mailing Address - City:FLANDREAU
Mailing Address - State:SD
Mailing Address - Zip Code:57028
Mailing Address - Country:US
Mailing Address - Phone:605-997-2471
Mailing Address - Fax:605-997-2418
Practice Address - Street 1:203 N ELK STREET
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:SD
Practice Address - Zip Code:57026
Practice Address - Country:US
Practice Address - Phone:605-542-7701
Practice Address - Fax:605-542-7291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center