Healthcare Provider Details

I. General information

NPI: 1942018122
Provider Name (Legal Business Name): SEIPATI VALERIE KGOMO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2024
Last Update Date: 12/20/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 SUNSET AVE 306
LAKE PARK MN
60506
US

IV. Provider business mailing address

178 MEADOW LN APT 203
DETROIT LAKES MN
56501-2455
US

V. Phone/Fax

Practice location:
  • Phone: 218-234-5238
  • Fax:
Mailing address:
  • Phone: 218-234-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number3747P1801X
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: