Provider Demographics
NPI:1902972334
Name:AVERA HOME MEDICAL EQUIPMENT, LLC
Entity type:Organization
Organization Name:AVERA HOME MEDICAL EQUIPMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIELEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:605-322-3984
Mailing Address - Street 1:PO BOX 5045
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5045
Mailing Address - Country:US
Mailing Address - Phone:605-322-1872
Mailing Address - Fax:605-322-1892
Practice Address - Street 1:3720 W 69TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-8192
Practice Address - Country:US
Practice Address - Phone:605-322-1881
Practice Address - Fax:605-322-1899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD51009EST001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN245935300Medicaid
SD9161914Medicaid
IA0561985Medicaid
MN245935300Medicaid
SD4653210004Medicare NSC