Basic Information
| Provider Information | |||||||||
| NPI: | 1124456629 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DBA MIDDLE PARK MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | KREMMLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804590399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243442 | ||||||||
| FaxNumber: | 9707249606 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 GRANBY PARK DRIVE SOUTH | ||||||||
| Address2: | |||||||||
| City: | GRANBY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804461169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243442 | ||||||||
| FaxNumber: | 9707249606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2013 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLECKLER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | MARSHALL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9702082907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC0050X | 010804 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital | 261QM1300X | 00.0000156 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QM1300X | 0000156 | CO | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR1300X | CO | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 04002770 | 05 | CO | MEDICAID |