Healthcare Provider Details

I. General information

NPI: 1902379159
Provider Name (Legal Business Name): GRAND ITASCA CLINIC AND HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

IV. Provider business mailing address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-1885
  • Fax: 218-999-1887
Mailing address:
  • Phone: 218-999-1885
  • Fax: 218-999-1887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State

VIII. Authorized Official

Name: JEAN MACDONELL
Title or Position: VP, CLINIC SERVICES
Credential:
Phone: 218-999-1510