Basic Information
| Provider Information | |||||||||
| NPI: | 1811307002 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA AT HOME | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AVERA@HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 604 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WESSINGTON SPRINGS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573822166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055394540 | ||||||||
| FaxNumber: | 6055394580 | ||||||||
| Practice Location | |||||||||
| Address1: | 604 1ST ST NE | ||||||||
| Address2: | |||||||||
| City: | WESSINGTON SPRINGS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 573822166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6055394540 | ||||||||
| FaxNumber: | 6055394580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIELEMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053223984 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | SD | Y | Agencies | In Home Supportive Care |
No ID Information.