Provider Demographics
NPI:1962473710
Name:STEVENS TRAVERSE GRANT PUBLIC HEALTH
Entity Type:Organization
Organization Name:STEVENS TRAVERSE GRANT PUBLIC HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:WINDOM-KIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:RN PHN DIRECTOR
Authorized Official - Phone:320-589-7425
Mailing Address - Street 1:621 PACIFIC AVENUE
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267
Mailing Address - Country:US
Mailing Address - Phone:320-589-7425
Mailing Address - Fax:320-589-7433
Practice Address - Street 1:621 PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267
Practice Address - Country:US
Practice Address - Phone:320-589-7425
Practice Address - Fax:320-589-7433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN328493251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
12745401OtherU CARE INSURANCE
144J9STOtherBCBS DME
8300111OtherMEDICA INSURANCE
8G534STOtherBCBS INSURANCE
01017242OtherPREFERRED ONE INSURANCE