Provider Demographics
NPI:1619003076
Name:COUNTY OF ITASCA
Entity type:Organization
Organization Name:COUNTY OF ITASCA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTING TECHNICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTYRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-327-6162
Mailing Address - Street 1:1209 SE 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3982
Mailing Address - Country:US
Mailing Address - Phone:218-327-2941
Mailing Address - Fax:218-327-5547
Practice Address - Street 1:1209 SE 2ND AVE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3982
Practice Address - Country:US
Practice Address - Phone:218-327-2941
Practice Address - Fax:218-327-5547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN241569251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN730000011OtherMEDICARE PTAN
MN54029ITOtherMNCARE BLUE PLUS
MN768553000Medicaid