Basic Information
| Provider Information | |||||||||
| NPI: | 1598094823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA QUEEN OF PEACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 N FOSTER ST | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573012966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059952000 | ||||||||
| FaxNumber: | 6059952441 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 N FOSTER ST | ||||||||
| Address2: | |||||||||
| City: | MITCHELL | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573012966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6059952000 | ||||||||
| FaxNumber: | 6059952441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2009 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | EKEREN | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6056688321 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 5590320 | 05 | SD | MEDICAID |