Organization
AVERA MCKENNAN
Active
Other names
Avera Dialysis Wagner
Organization subpart
No
Provider details
NPI number
Authorized official
RONALD JOSEPH PLACE MD (PRESIDENT/CEO)
(605) 322-7903
Entity
Organization
Contact information
Practice address
310 W SD HIGHWAY 46, WAGNER, SD 57380-9304
(605) 384-4980
(605) 384-4990
Mailing address
PO BOX 5045, PFS PROV ENRLLMT, SIOUX FALLS, SD 57117-5045
(605) 322-6404
Taxonomy
Speciality
Code
Description
License number
State
261QE0700X
End-Stage Renal Disease (ESRD) Treatment Clinic/Center
Primary
10563
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1538527106
WELLMARK BCBS
SD
Enumeration date
02/10/2016
Last updated
10/04/2023
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