Healthcare Provider Details

I. General information

NPI: 1245929413
Provider Name (Legal Business Name): PAUL KIM GEORGESON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 3RD AVE NE APT 2
DEVILS LAKE ND
58301-2103
US

IV. Provider business mailing address

502 12TH AVE SE LOT 19
DEVILS LAKE ND
58301-3815
US

V. Phone/Fax

Practice location:
  • Phone: 507-216-2448
  • Fax:
Mailing address:
  • Phone: 507-512-9267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: