Basic Information
| Provider Information | |||||||||
| NPI: | 1881760866 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AVERA HOME MEDICAL EQUIPMENT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 E 21ST ST | ||||||||
| Address2: | PO BOX 5045 | ||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571051016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053221872 | ||||||||
| FaxNumber: | 6053221892 | ||||||||
| Practice Location | |||||||||
| Address1: | 115 N 6TH ST | ||||||||
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| City: | ESTHERVILLE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 513342228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7123623568 | ||||||||
| FaxNumber: | 7123623570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 10/31/2016 | ||||||||
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| AuthorizedOfficialLastName: | DIELEMAN | ||||||||
| AuthorizedOfficialFirstName: | SANDRA | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 6053223984 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 132004906 | IA | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 956635000 | 05 | MN | MEDICAID | 0456632 | 05 | IA | MEDICAID |