Basic Information
| Provider Information | |||||||||
| NPI: | 1003869082 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY MEMORIAL HOSPITAL ASSOCIATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 512 SKYLINE BLVD | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557203787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188794641 | ||||||||
| FaxNumber: | 2188794641 | ||||||||
| Practice Location | |||||||||
| Address1: | 512 SKYLINE BLVD | ||||||||
| Address2: | |||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 557203787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188794641 | ||||||||
| FaxNumber: | 2188794641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 12/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | BREUER | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2188787621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 282NC0060X | 331457 | MN | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 695045100 | 05 | MN | MEDICAID |