Healthcare Provider Details

I. General information

NPI: 1669426631
Provider Name (Legal Business Name): GRAND ITASCA CLINIC AND HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 GOLF COURSE RD
GRAND RAPIDS MN
55744-8648
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-3401
  • Fax: 218-999-1461
Mailing address:
  • Phone: 612-672-6740
  • Fax: 612-884-3592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number330789
License Number StateMN

VIII. Authorized Official

Name: TODD CHRISTENSEN
Title or Position: VP OF FINANCE
Credential:
Phone: 218-999-1702