Healthcare Provider Details

I. General information

NPI: 1669390746
Provider Name (Legal Business Name): KEVIN MATTHEW ELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

4072 BIA 2 SOUTH
SAINT JOHN ND
58369
US

IV. Provider business mailing address

4072 BIA 2 SOUTH
SAINT JOHN ND
58369
US

V. Phone/Fax

Practice location:
  • Phone: 701-477-0670
  • Fax:
Mailing address:
  • Phone: 701-477-0670
  • 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: