Organization
AVERA MCKENNAN
Active
Other names
AVERA MEDICAL GROUP REVILLO
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID FLICEK (PRESIDENT/CEO)
(605) 322-7915
Entity
Organization
Contact information
Practice address
305 N 2ND AVE, REVILLO, SD 57259-0006
(605) 623-4695
(605) 623-4318
Mailing address
901 E VIRGIL AVE, MILBANK, SD 57252-2124
(605) 432-4538
(605) 432-5412
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
SD
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
228L6RE
MN BLUE CROSS-REVILLO P#
MN
05
—
246933200
—
MN
01
—
4996359
SD BLUE CROSS-REVILLO P#
SD
05
—
5800490
—
SD
01
—
9204609
DAKOTACARE REVILLO PROV#
SD
Enumeration date
08/15/2006
Last updated
07/02/2021
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