1114003795 NPI number — GRAND PORTAGE RESERVATION BUSINESS COMMITTEE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114003795 NPI number — GRAND PORTAGE RESERVATION BUSINESS COMMITTEE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAND PORTAGE RESERVATION BUSINESS COMMITTEE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114003795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
62 UPPER ROAD
Provider Second Line Business Mailing Address:
PO 428
Provider Business Mailing Address City Name:
GRAND PORTAGE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55605-0428
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-475-2235
Provider Business Mailing Address Fax Number:
218-475-2261

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
62 UPPER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND PORTAGE
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55605-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-475-2235
Provider Business Practice Location Address Fax Number:
218-475-2261
Provider Enumeration Date:
10/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DESCHAMPE
Authorized Official First Name:
NORMAN
Authorized Official Middle Name:
Authorized Official Title or Position:
TRIBAL CHAIRMAN
Authorized Official Telephone Number:
218-475-2277

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  0321 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 283767600 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com