Basic Information
Provider Information | |||||||||
NPI: | 1619962321 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DBA MIDDLE PARK MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 399 | ||||||||
Address2: |   | ||||||||
City: | KREMMLING | ||||||||
State: | CO | ||||||||
PostalCode: | 804590399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9707243171 | ||||||||
FaxNumber: | 9707249606 | ||||||||
Practice Location | |||||||||
Address1: | 214 S.4TH STREET | ||||||||
Address2: |   | ||||||||
City: | KREMMLING | ||||||||
State: | CO | ||||||||
PostalCode: | 80459 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9707243171 | ||||||||
FaxNumber: | 9707249606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2005 | ||||||||
LastUpdateDate: | 09/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HORNER | ||||||||
AuthorizedOfficialFirstName: | MIKEALENA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 9707243171 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 00.0000156 | CO | N |   | Hospitals | General Acute Care Hospital | Critical Access | 275N00000X | 0127 | CO | N |   | Hospital Units | Medicare Defined Swing Bed Unit |   | 282NC0060X | 0127 | CO | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 05090006 | 05 | CO |   | MEDICAID |