Healthcare Provider Details

I. General information

NPI: 1962509364
Provider Name (Legal Business Name): HOPE HOUSE OF ITASCA COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 CROMELL DR
GRAND RAPIDS MN
55744-3571
US

IV. Provider business mailing address

2002 CROMELL DR
GRAND RAPIDS MN
55744-3571
US

V. Phone/Fax

Practice location:
  • Phone: 218-326-1443
  • Fax: 218-326-4390
Mailing address:
  • Phone: 218-326-1443
  • Fax: 218-326-4390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number801078
License Number StateMN

VIII. Authorized Official

Name: MS. SUSAN LYNN MARCHEL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 218-327-9944