Healthcare Provider Details

I. General information

NPI: 1780506410
Provider Name (Legal Business Name): EVARISTE NKUNDABATWARE BUSANGA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 21ST ST S
FARGO ND
58103-1430
US

IV. Provider business mailing address

407 21ST ST S
FARGO ND
58103-1430
US

V. Phone/Fax

Practice location:
  • Phone: 701-929-0985
  • Fax: 701-929-0985
Mailing address:
  • Phone: 701-929-0985
  • Fax: 701-929-0985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberBUS733333
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: