Avera Tyler
Organization Active NPI Rural Health Clinic/Center · Lake Benton, MN
NPI 1003869892 · NPPES record last updated Jun 12, 2026
Key facts
- NPI
- 1003869892
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 261QR1300X
- Legal business name
- AVERA TYLER
- Practice address
- 109 E Benton St
Lake Benton, MN 56149-1309 - Phone
- (507) 368-4323
- Fax
- (507) 368-4546
- NPI assigned
- May 19, 2006
- Organization subpart
- Yes
- Parent organization (as reported)
- AVERA MEDICAL GROUP TYLER
Authorized official
- Name
- Debbie Streier
- Title
- Ceo
- Phone
- (507) 537-9160
Owners & managing parties with NPI records 17
-
Quentin James Fixen, D.C.
-
Curtis Ronald Louwagie, M.D.
-
Jill M Vroman, DO
Other NPIs on the same Medicare enrollment 3
Other NPIs with the same Medicare PAC ID 4
Member of 1
Related certifications (CCN) 1
Facilities with the same owner 91
Practitioners 47
-
Heidi Ann Hansen, APRN, CNP
-
Kassandra Elizabeth Anderson, FNP-C
-
Jill Marie Jay, FNP
-
Maneesh C. Kanal, MD
-
Martin Heinz Janning, M.D.
-
Steven L Kidd, MD
-
Enrico Ocampo, M.D., FACP, FACE
-
Arthur J Rillo, MD
-
Wade Robert Sendelbach, MSN, APRN, CNP
-
Rachelle Deutz, RD, LD
-
Laura Anne Dorman, PA-C
-
Marcia S Kells, RN CNP
-
Katherine Joan Mackenzie, FNP-BC
-
Kevin Jeffrey Mahoney, D.P.M.
-
Jessica Joy Moriarty, CNP
-
Amy Frances Nicolas, CNP
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 24D0934038 | Avera Medical Group Lake Benton | Certificate of waiver | Sep 28, 2027 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (3 enrollments) in MN
Rural health clinic certification: CCN 243470
- Legal name
- AVERA TYLER
- Doing business as
- AVERA MEDICAL GROUP TYLER
- Certification status
- Active
- Provider type (POS)
- Rural health clinic
- Participating since
- Jun 11, 2014
- Last certification
- Jun 11, 2014
- Ownership / control type
- 2B
- Most recent change of ownership
- Mar 1, 2016 (1 total)
- Organization structure
- Corporation · Non-profit
- Incorporated
- Nov 30, 1961 in MN
- Enrollment address
- 109 E Benton St
Lake Benton, MN 56149-1309 - Related CCNs
- 241348
All disclosed owners & managing parties 21
| Name | Role | Since | Share |
|---|---|---|---|
| James Francis Dover |
Corporate Officer |
Oct 23, 2023 | |
| Joyce H Strootman |
Corporate Director |
Jul 1, 2015 | |
| Quentin J Fixen |
Corporate Director |
Jul 1, 2018 | |
| Jill Vroman |
Corporate Director |
Jul 1, 2023 | |
| Debra Ann Streier |
Corporate Officer |
Feb 1, 2021 | |
| George L Jorgenson |
Corporate Director |
Mar 1, 2016 | |
| Tim O'Leary |
Corporate Director |
Jul 1, 2023 | |
| Jodelle a Zimmerman |
Corporate Director |
Jul 1, 2018 | |
| Sharon Hennen |
Corporate Director |
Jul 1, 2023 | |
| Gregory W Goepferich |
Corporate Director |
Jul 1, 2020 | |
| Amanda Sieling |
Corporate Director |
Jul 1, 2018 | |
| Lavonne Annette Koenen |
Corporate Director |
Jul 1, 2020 | |
| Thomas J Kooiman |
Corporate Officer |
May 29, 2022 | |
| Operational/Managerial Control | May 29, 2022 | ||
| Avera Marshall |
5% Or Greater Direct Ownership Interest | Mar 1, 2016 | 100% |
| Operational/Managerial Control | Mar 1, 2016 | ||
| Laurie J Johansen |
Corporate Director |
Mar 1, 2016 | |
| Christy Ann Coudron |
Corporate Officer |
Sep 1, 2020 | |
| Stephen Menzies Crim |
Corporate Director |
Jul 1, 2019 | |
| Mark M Vortherms |
Corporate Officer |
Sep 29, 2020 | |
| Julie Lautt |
Corporate Officer |
Mar 1, 2020 | |
| Curtis Ronald Louwagie |
Corporate Director |
Jul 1, 2018 | |
| Avera Health |
5% Or Greater Indirect Ownership Interest | Mar 1, 2016 | 100% |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20040320000679 | MN | Part B Supplier - Clinic/Group Practice | 1557252533 |
Receives reassigned benefits from 6 practitioners 1 other NPI on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Lake Benton, MN; Tyler, MN |
| O20161129000531 | MN | Part a Provider - Rural Health Clinic | 9638088537 | Practice locations: Lake Benton, MN |
| O20170630001868 | MN | Part B Supplier - Clinic/Group Practice | 9638088537 |
Receives reassigned benefits from 58 practitioners 3 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Tyler, MN; Lake Benton, MN; Ivanhoe, MN |
National Provider Directory
- Part of
- Avera Tyler
Locations
1210 E College Dr
Marshall, MN 56258
Phone (507) 247-5921
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Rural Health Clinic/Center | 261QR1300X | Yes |
Addresses
Primary practice location
109 E Benton St
Lake Benton, MN 56149-1309
Mailing address
PO Box 86370
Sioux Falls, SD 57118-6370
Phone (507) 368-4323
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 9732144 | Medicaid | MN | |
| 5T014TY | Other | MN | BLUE CROSS BLUE SHIELD |
Other names
- Avera Lake Benton Clinic
- Avera Medical Group Lake Benton
Other providers in Lake Benton, MN
All providers in Lake Benton, MN · Rural Health Clinic/Center in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 12, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.