Basic Information
| Provider Information | |||||||||
| NPI: | 1851848444 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AVERA MCKENNAN | ||||||||
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| OtherOrganizationName: | AVERA MEDICAL GROUP OPTOMETRY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 S MARION ROAD | ||||||||
| Address2: | STE 125 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571063645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053223790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 S MARION ROAD | ||||||||
| Address2: | STE 125 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571063645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053223790 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2016 | ||||||||
| LastUpdateDate: | 10/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | FLICEK | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6053228000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.