Individual
REVEND MAII
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
506 FOXTAIL DR E, WEST FARGO, ND 58078-7965
(701) 850-2561
Mailing address
4420 CALICO DR S APT 239, FARGO, ND 58104-5579
(701) 306-5950
Taxonomy
Speciality
Code
Description
License number
State
3747P1801X
Personal Care Attendant
Primary
—
—
376J00000X
Homemaker
Primary
—
—
Other
Enumeration date
06/24/2026
Last updated
07/08/2026
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