Healthcare Provider Details

I. General information

NPI: 1821684002
Provider Name (Legal Business Name): KELENT CHAVEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2020
Last Update Date: 12/12/2020
Certification Date: 12/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 BURDICK EXPY E
MINOT ND
58701-4768
US

IV. Provider business mailing address

36 DUNDEE DR APT 2
MINOT AFB ND
58704-2003
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-7900
  • Fax:
Mailing address:
  • Phone: 512-658-5727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberTECH1748
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: