Provider Demographics
NPI:1679541825
Name:AVERA QUEEN OF PEACE
Entity type:Organization
Organization Name:AVERA QUEEN OF PEACE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:EKEREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-668-8321
Mailing Address - Street 1:525 N FOSTER ST
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-2966
Mailing Address - Country:US
Mailing Address - Phone:605-995-2000
Mailing Address - Fax:605-995-2441
Practice Address - Street 1:525 N FOSTER ST
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-2966
Practice Address - Country:US
Practice Address - Phone:605-995-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVERA QUEEN OF PEACE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-14
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD100-1023333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0100130Medicaid
SD0100130Medicaid