Provider Demographics
NPI:1285964494
Name:WAGNER COMMUNITY MEMORIAL HOSPITAL AVERA
Entity type:Organization
Organization Name:WAGNER COMMUNITY MEMORIAL HOSPITAL AVERA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SLABA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-384-3611
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:513 3RD ST SW
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-0280
Mailing Address - Country:US
Mailing Address - Phone:605-384-3611
Mailing Address - Fax:605-384-3232
Practice Address - Street 1:513 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380-9675
Practice Address - Country:US
Practice Address - Phone:605-384-3611
Practice Address - Fax:605-384-3232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD43D0407563291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory