Healthcare Provider Details

I. General information

NPI: 1801499744
Provider Name (Legal Business Name): CRYSTAL JOY MELAAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/20/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WESTERN AVE N
MADDOCK ND
58348
US

IV. Provider business mailing address

PO BOX 371
MADDOCK ND
58348-0371
US

V. Phone/Fax

Practice location:
  • Phone: 701-351-0460
  • Fax:
Mailing address:
  • Phone: 701-351-0460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number1463732
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: