Healthcare Provider Details

I. General information

NPI: 1821993163
Provider Name (Legal Business Name): ELVIS BASIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2703 PAINT BALL WAY
BISMARCK ND
58554
US

IV. Provider business mailing address

403 3RD AVE NW APT 3
MANDAN ND
58554-3019
US

V. Phone/Fax

Practice location:
  • Phone: 701-226-2791
  • Fax:
Mailing address:
  • Phone: 701-226-2791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberBAS90-5822
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: