Basic Information
| Provider Information | |||||||||
| NPI: | 1538774377 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 399 | ||||||||
| Address2: | |||||||||
| City: | KREMMLING | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804590399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708875800 | ||||||||
| FaxNumber: | 9708875891 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 GRANBY PARK SOUTH | ||||||||
| Address2: | |||||||||
| City: | GRANBY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 804468900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708875800 | ||||||||
| FaxNumber: | 9708875891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2020 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | CLECKLER | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | MARSHALL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9702082907 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 04003281 | 05 | CO | MEDICAID |