Healthcare Provider Details

I. General information

NPI: 1003650029
Provider Name (Legal Business Name): GORDON STRAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 NW 4TH ST
GRAND RAPIDS MN
55744-2212
US

IV. Provider business mailing address

1125 SW 1ST ST
GRAND RAPIDS MN
55744-3407
US

V. Phone/Fax

Practice location:
  • Phone: 218-327-0875
  • Fax:
Mailing address:
  • Phone: 218-259-0003
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: