Provider Demographics
NPI:1659436954
Name:GRAND PORTAGE HEALTH SERVICE
Entity Type:Organization
Organization Name:GRAND PORTAGE HEALTH SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:BUSHARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-475-2235
Mailing Address - Street 1:62 UPPER ROAD
Mailing Address - Street 2:
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 ROAD
Practice Address - Street 2:
Practice Address - City:GRAND PORTAGE
Practice Address - State:MN
Practice Address - Zip Code:55605-0428
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:2006-12-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service