Healthcare Provider Details

I. General information

NPI: 1114003795
Provider Name (Legal Business Name): GRAND PORTAGE RESERVATION BUSINESS COMMITTEE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 11/12/2025
Certification Date: 11/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 UPPER RD
GRAND PORTAGE MN
55605-3010
US

IV. Provider business mailing address

62 UPPER RD
GRAND PORTAGE MN
55605-3010
US

V. Phone/Fax

Practice location:
  • Phone: 218-475-2235
  • Fax: 218-475-2261
Mailing address:
  • Phone: 218-475-2235
  • Fax: 218-475-2261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3416L0300X
TaxonomyLand Ambulance
License Number0321
License Number StateMN

VIII. Authorized Official

Name: MR. ROBERT DESCHAMPE
Title or Position: CHAIRMAN
Credential:
Phone: 218-475-2277