Healthcare Provider Details

I. General information

NPI: 1396661468
Provider Name (Legal Business Name): REVEND MAII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 FOXTAIL DR E
WEST FARGO ND
58078-7965
US

IV. Provider business mailing address

4420 CALICO DR S APT 239
FARGO ND
58104-5579
US

V. Phone/Fax

Practice location:
  • Phone: 701-850-2561
  • Fax:
Mailing address:
  • Phone: 701-306-5950
  • 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: