Basic Information
| Provider Information | |||||||||
| NPI: | 1164064358 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH PARK MEDICAL CENTER - WALDEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | KREMMLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804590399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707243171 | ||||||||
| FaxNumber: | 9707249446 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 MCKINLEY STREET | ||||||||
| Address2: | |||||||||
| City: | WALDEN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804809708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9707234255 | ||||||||
| FaxNumber: | 9707234268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2019 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLASEN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | SR. DIRECTOR, BUSINESS OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3076992413 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 9000143431 | 05 | CO | MEDICAID |