Basic Information
Provider Information | |||||||||
NPI: | 1730756669 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 399 | ||||||||
Address2: |   | ||||||||
City: | KREMMLING | ||||||||
State: | CO | ||||||||
PostalCode: | 804590399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708875800 | ||||||||
FaxNumber: | 9708875891 | ||||||||
Practice Location | |||||||||
Address1: | 214 S 4TH ST | ||||||||
Address2: |   | ||||||||
City: | KREMMLING | ||||||||
State: | CO | ||||||||
PostalCode: | 804595065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708875800 | ||||||||
FaxNumber: | 9708875891 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2021 | ||||||||
LastUpdateDate: | 06/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLECKLER | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: | MARSHALL | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9702082907 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | KREMMLING MEMORIAL HOSPITAL DISTRICT | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X |   |   | Y |   | Hospital Units | Medicare Defined Swing Bed Unit |   |
ID Information
ID | Type | State | Issuer | Description | 9000141589 | 05 | CO |   | MEDICAID |