Healthcare Provider Details

I. General information

NPI: 1396501052
Provider Name (Legal Business Name): ISAIAH KELLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 1ST AVE E
MC LAUGHLIN SD
57642-2028
US

IV. Provider business mailing address

425 MAIN ST S
MINOT ND
58701-4414
US

V. Phone/Fax

Practice location:
  • Phone: 808-830-7595
  • Fax: 833-846-8690
Mailing address:
  • Phone: 808-830-7595
  • Fax: 833-846-8690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: