Basic Information
Provider Information | |||||||||
NPI: | 1134790041 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AVERA HOME MEDICAL EQUIPMENT OF LAKES REGIONAL HEALTHCARE, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 5045 | ||||||||
Address2: |   | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571175045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053221872 | ||||||||
FaxNumber: | 6053221892 | ||||||||
Practice Location | |||||||||
Address1: | 2301 HIGHWAY 71 STE D | ||||||||
Address2: |   | ||||||||
City: | SPIRIT LAKE | ||||||||
State: | IA | ||||||||
PostalCode: | 513601184 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7123396140 | ||||||||
FaxNumber: | 7123396145 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2021 | ||||||||
LastUpdateDate: | 09/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DIELEMAN | ||||||||
AuthorizedOfficialFirstName: | SANDRA | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 6053223984 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.