Healthcare Provider Details

I. General information

NPI: 1104607282
Provider Name (Legal Business Name): REBECCA KELLEMS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2023
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 PITCHER PARK SE
DEVILS LAKE ND
58301-3909
US

IV. Provider business mailing address

31 PITCHER PARK SE
DEVILS LAKE ND
58301-3909
US

V. Phone/Fax

Practice location:
  • Phone: 701-230-1474
  • Fax:
Mailing address:
  • Phone: 701-230-1474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: