Healthcare Provider Details

I. General information

NPI: 1467776062
Provider Name (Legal Business Name): COOK COUNTY COUNCIL ON AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2010
Last Update Date: 03/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 N BROADWAY AVE
GRAND MARAIS MN
55604-5015
US

IV. Provider business mailing address

PO BOX 67
GRAND MARAIS MN
55604-0067
US

V. Phone/Fax

Practice location:
  • Phone: 218-387-2660
  • Fax: 218-387-2317
Mailing address:
  • Phone: 218-387-2660
  • Fax: 218-387-2317

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY GREEN
Title or Position: DIRECTOR
Credential:
Phone: 218-387-2660