Organization
AVERA MCKENNAN
Active
Other names
AVERA MEDICAL GROUP WILMOT
Organization subpart
No
Provider details
NPI number
Authorized official
DAVID FLICEK (PRESIDENT/CEO)
(605) 322-7916
Entity
Organization
Contact information
Practice address
409 4TH ST, WILMOT, SD 57279-2214
(605) 938-4351
(605) 938-4351
Mailing address
409 4TH ST, WILMOT, SD 57279-2214
(605) 938-4351
(605) 938-4351
Taxonomy
Speciality
Code
Description
License number
State
261QR1300X
Rural Health Clinic/Center
Primary
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
43D0901649
CLIA #
SD
05
—
5300010
—
SD
Enumeration date
09/20/2006
Last updated
09/10/2020
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