MEDICARE: GRACE EDITH LINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	B772-020-465-216	MN

General Provider Information

NPI Number	:	1790318186
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE EDITH LINE

Provider Business Mailing Address
First Line	:	PO BOX 15192
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55815-0192
Country	:	US
Telephone Number	:	218-481-5357
Fax Number	:

Provider Business Practice Location Address
First Line	:	2934 168TH LN NW
Second Line	:
City	:	ANDOVER
State	:	MN
Zip	:	55304-1928
Country	:	US
Telephone Number	:	218-481-5357
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2020
Last Update Date	:	02/13/2020

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Directions to “ GRACE EDITH LINE ” Practice Location

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