Basic Information
| Provider Information | |||||||||
| NPI: | 1144225129 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA BRADY HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 525 N FOSTER ST | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573012966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059955200 | ||||||||
| FaxNumber: | 6059952441 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 S OHLMAN ST | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573013109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059967701 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | EKEREN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6056688322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AVERA QUEEN OF PEACE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 10652 | SD | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0151182 | 05 | SD | MEDICAID |