Provider Demographics
NPI:1114003795
Name:GRAND PORTAGE RESERVATION BUSINESS COMMITTEE
Entity Type:Organization
Organization Name:GRAND PORTAGE RESERVATION BUSINESS COMMITTEE
Other - Org Name:GRAND PORTAGE AMBULANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TRIBAL CHAIRMAN
Authorized Official - Prefix:MR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESCHAMPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-475-2277
Mailing Address - Street 1:62 UPPER ROAD
Mailing Address - Street 2:PO 428
Mailing Address - City:GRAND PORTAGE
Mailing Address - State:MN
Mailing Address - Zip Code:55605-0428
Mailing Address - Country:US
Mailing Address - Phone:218-475-2235
Mailing Address - Fax:218-475-2261
Practice Address - Street 1:62 UPPER RD
Practice Address - Street 2:
Practice Address - City:GRAND PORTAGE
Practice Address - State:MN
Practice Address - Zip Code:55605-3010
Practice Address - Country:US
Practice Address - Phone:218-475-2235
Practice Address - Fax:218-475-2261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03213416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN283767600Medicaid
MN283767600Medicaid