Basic Information
| Provider Information | |||||||||
| NPI: | 1841511904 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA ST MARYS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MARYHOUSE ADULT DAY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5045 | ||||||||
| Address2: | CBO PALM PLACE PRVENROLLMT | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571175045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053226428 | ||||||||
| FaxNumber: | 6053226499 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 E SIOUX AVE | ||||||||
| Address2: | |||||||||
| City: | PIERRE | ||||||||
| State: | SD | ||||||||
| PostalCode: | 57501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052243100 | ||||||||
| FaxNumber: | 6052248339 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2010 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | MIKEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6052243144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 311ZA0620X | 10662 | SD | Y | Nursing & Custodial Care Facilities | Custodial Care Facility | Adult Care Home |
No ID Information.