Healthcare Provider Details

I. General information

NPI: 1942112362
Provider Name (Legal Business Name): SAMUEL EADES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4614 MIKE COLALILLO DR
DULUTH MN
55807-2732
US

IV. Provider business mailing address

4500 DAVIS RD
GRAND RAPIDS MN
55744-8388
US

V. Phone/Fax

Practice location:
  • Phone: 218-522-0601
  • Fax:
Mailing address:
  • Phone:
  • Fax: 218-522-0601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: