Healthcare Provider Details

I. General information

NPI: 1528987237
Provider Name (Legal Business Name): BLAYNE CHAMPAGNE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9910 BIA RD 25 P.O BOX 783
DUNSEITH ND
58329
US

IV. Provider business mailing address

9910 BIA RD 25 P.O BOX 783
DUNSEITH ND
58329
US

V. Phone/Fax

Practice location:
  • Phone: 701-471-1026
  • Fax:
Mailing address:
  • Phone: 701-472-1026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: