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Organization

COUNTY OF ITASCA

Active
Organization subpart
No

Provider details

NPI number
Authorized official
MS. WENDY MCINTYRE (ACCOUNTING TECHNICIAN)
(218) 327-6162
Entity
Organization

Contact information

Practice address
1209 SE 2ND AVE, GRAND RAPIDS, MN 55744-3982
(218) 327-2941
(218) 327-5547
Mailing address
1209 SE 2ND AVE, GRAND RAPIDS, MN 55744-3982
(218) 327-2941
(218) 327-5547

Taxonomy

Speciality
Code
Description
License number
State
251K00000X
Public Health or Welfare Agency
Primary
241569
MN

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
54029IT
MNCARE BLUE PLUS
MN
01
730000011
MEDICARE PTAN
MN
05
768553000
MN
Enumeration date
02/27/2007
Last updated
09/04/2013
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