Provider Demographics
NPI:1487613287
Name:GRACEVILLE HEALTH CENTER
Entity type:Organization
Organization Name:GRACEVILLE HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:BODENSTEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-435-7633
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:115 W 2ND ST
Mailing Address - City:GRACEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:56240-4847
Mailing Address - Country:US
Mailing Address - Phone:320-748-7223
Mailing Address - Fax:320-748-7225
Practice Address - Street 1:104 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHOKIO
Practice Address - State:MN
Practice Address - Zip Code:56221
Practice Address - Country:US
Practice Address - Phone:320-324-7500
Practice Address - Fax:320-324-7563
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACEVILLE HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-21
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN102823500Medicaid
MN243405BMedicare PIN